A clear-eyed view of obesity

Mixed into the jumbled bouillabaisse of our current healthcare system (from which I decided to elide the scare quotes) is the seemingly beneficent concept of quality improvement.  This two-word phrase has lots of different connotations, but for the purposes of this post I’m going to refer only to the way QI insinuates itself into how medical practices are paid.  As the fee-for-service horse wheezes its way toward the glue factory, alternative models have emerged.  One ascendant approach is to reward practices that meet some benchmark for delivering quality care.  For example, if Li’l Stinkers Pediatric Associates reduces the number of emergency room visits for its asthmatic patients by 10%, Leviathan Insurance Co. will pay out a certain amount to the practice.  Follow?

The nice thing is that, so far as I can tell, practices are given some say in which benchmarks they’ll try to hit.  (This is just what I’ve observed personally, so that may not be a 100% accurate statement.)  When the providers in my own practice met to discuss how we might pursue quality-based reimbursement, we had several alternatives from which to choose.  We ended up going with something akin to the asthma management goals limned above.

The goal we soundly, unanimously rejected outright?  Trying to achieve significant reduction in body mass index for our overweight patients.  We are all too familiar with the dismal results consistently shown by medical weight-loss programs to want to pin our practice’s finances on their success.  This is not to say that we don’t take seriously the goal of helping our patients reach and maintain a healthy weight, just that we are realistic when it comes to how successful such efforts often are and don’t want to lose money as a result.

It’s easy to get the impression when you read about how hard it is for people to lose weight sustainably that the problem is simply a failure of willpower.  That overweight people are that way because of a character flaw, essentially.  Or, in the words of an esteemed colleague, the result of a slow, steady gorging process combined with assal horizontology.  For people who do not struggle with their weight, an additional assumption is that because it’s easy for them it should be no great matter for overweight people to lose weight if they really wanted.  Right?


Tara Parker-Pope’s recent article in the Times about how hard it is to lose weight was eye-opening for me.  Try as I might to think otherwise, I find myself making those same assumptions I describe above.  I don’t have much of a sweet tooth, and I’ve always enjoyed exercise as recreation.  When I’ve had patients who have reported sincere attempts at losing weight without success, part of me remained skeptical.  Reading this was very illuminating:

 While researchers have known for decades that the body undergoes various metabolic and hormonal changes while it’s losing weight, the Australian team detected something new. A full year after significant weight loss, these men and women remained in what could be described as a biologically altered state. Their still-plump bodies were acting as if they were starving and were working overtime to regain the pounds they lost. For instance, a gastric hormone called ghrelin, often dubbed the “hunger hormone,” was about 20 percent higher than at the start of the study. Another hormone associated with suppressing hunger, peptide YY, was also abnormally low. Levels of leptin, a hormone that suppresses hunger and increases metabolism, also remained lower than expected. A cocktail of other hormones associated with hunger and metabolism all remained significantly changed compared to pre-dieting levels. It was almost as if weight loss had put their bodies into a unique metabolic state, a sort of post-dieting syndrome that set them apart from people who hadn’t tried to lose weight in the first place.

As interesting as it may be to learn the science behind refractory obesity, however, it was the story of two married, formerly obese people who have managed to keep the weight off that really communicated how much effort is truly required.  Of the wife, Parker-Pope writes:

She also weighs everything in the kitchen. She knows that lettuce is about 5 calories a cup, while flour is about 400. If she goes out to dinner, she conducts a Web search first to look at the menu and calculate calories to help her decide what to order. She avoids anything with sugar or white flour, which she calls her “gateway drugs” for cravings and overeating. She has also found that drinking copious amounts of water seems to help; she carries a 20-ounce water bottle and fills it five times a day. She writes down everything she eats. At night, she transfers all the information to an electronic record. Adam also keeps track but prefers to keep his record with pencil and paper.


Bridge supports her careful diet with an equally rigorous regimen of physical activity. She exercises from 100 to 120 minutes a day, six or seven days a week, often by riding her bicycle to the gym, where she takes a water-aerobics class. She also works out on an elliptical trainer at home and uses a recumbent bike to “walk” the dog, who loves to run alongside the low, three-wheeled machine. She enjoys gardening as a hobby but allows herself to count it as exercise on only those occasions when she needs to “garden vigorously.” Adam is also a committed exerciser, riding his bike at least two hours a day, five days a week.

Janice Bridge has used years of her exercise and diet data to calculate her own personal fuel efficiency. She knows that her body burns about three calories a minute during gardening, about four calories a minute on the recumbent bike and during water aerobics and about five a minute when she zips around town on her regular bike.

Friends, that woman works much, much harder to stay thin than I do.  I’m tentatively planning to run a marathon this year, and she kicks my ass when it comes to how much exercise she gets.  I eat a healthy diet, heavy on vegetables and fish, but I don’t pay nearly as much attention to what I eat as she does.  I know I put on a few additional pounds over the holidays, but it took one week of my regular routine for it to come off.  Reading that, it looks like I’m bragging, but that’s actually the opposite of what I’m trying to communicate.  There’s nothing about my ability to stay thin that warrants admiration, certainly not compared to those who really have to strive to obtain the same result.

The entire article is worth a read, lengthy though it may be.  It quite effectively clarified just how hard long-term weight loss really is.  My only question now is how I might modify my own approach with overweight patients.  Even if we don’t make it the basis of a financial incentive, it’s obviously of paramount importance that we continue to address the issue.  I’ve typically focused on small, sustainable changes, viewing them as a more realistic recommendation than trying to get patients and their families to sign on to a much more radical change like what the Bridges made for themselves.  But even if sustained, it looks like small changes just won’t work, except perhaps if further changes accumulate over time.

The most effective thing would likely be to focus as much as possible on prevention.  The Let’s Go program seems to be having some success, with its easy-to-understand guidelines.  In any case, whatever modifications I make in my practice will be done by a much less smug provider.

Update: For those interested in the subject, I’d recommend Megan McArdle’s follow-up article.  (Hat tip to Will in the comments below.)

Russell Saunders

Russell Saunders is the ridiculously flimsy pseudonym of a pediatrician in New England. He has a husband, three sons, daughter, cat and dog, though not in that order. He enjoys reading, running and cooking. He can be contacted at blindeddoc using his Gmail account. Twitter types can follow him @russellsaunder1.


  1. What’s amusing to me about the Parker-Pope article is that it confirms the idea that “eat less and exercise” is the only way to lose weight and keep it off.

    It’s just a lot harder than “two dinner rolls instead of three” and “walk up the stairs instead of taking the elevator”. That’s the part that people have trouble with–that the things they think of as “less food” and “extra work” are, in fact, infinitesimal in the scheme of what they do.

  2. Wake up. double check yourself.
    And whatever the FUCK you do, don’t let yourself think of someone overweight as LAZY.
    There are Serious Health Consequences to the level of care that a person receives — and the level of care that a person receives depends on weight (as it does on skin color).
    Next, be prepared for mental health issues (both depression and abuse issues) — a good deal of overweight/obese people have problems with getting “addicted” to food (the quotes are unnecessary, except that it’s a mental addiction, like video games.)

  3. I’ve been pondering a post on the subject myself. Both Parker-Pope’s piece and McArdle’s response.

    A friend of mine has determined that she desperately needs to lose weight and that she’s going to work on it by willpower, willpower, willpower. It broke my heart, because I am pretty sure that she is doomed to fail. The article does a great job of explaining how difficult it is to lose weight and keep it off, but doesn’t explain the next part: it’s more than what most people are capable of doing. Period. At least, by sheer willpower and planning alone.

    If I were in the diet-giving advice, it would be that if it is making you miserable, it’s likely not sustainable. Rather, keep trying new things. I tried everything until I gave up and found the thing that worked. The thing that, if I’d explained to someone what I was doing, would be proof positive that I was not actually serious about losing weight.

    • That is certainly true. So much of medical and societal thought involving people’s weight seems to assume that everyone should be skinny. Very little is focused on deciding whether or not you’re actually happy where you are.

      • well, sir, are you HAPPY when everyone calls you a whale? When people talk with you and assume you’re good at oral sex, because you’re FAT?
        Society can’t change biology, and thin folks are more attractive.

        • Thin folks have spindly legs, toothpick arms, no hips, and no tits.

  4. This issue is seriously one of my bugaboos (as I believe Dr. Saunders is aware). Over 10 years, between 95% and 98% of people who lose weight gain it back. Treatment for heroin addiction has a better success rate. As I just read in a different post today, “Lost in the discussion of stigma, the reporters and experts have seemingly forgotten one very important fact. That fact? We simply don’t yet have a reproducible and reliable treatment program that results in significant and sustained weight loss in children.” http://www.weightymatters.ca/2012/01/real-problem-with-those-controversial.html Ditto adults.

    I used to be significantly overweight, and believed that I lacked willpower. I am now not significantly overweight (except when I’ve just had my children…). So I am in the 2-5% who have kept significant weight off. Well, it’s eight years now, but I’m pretty sure it will be 10. But my experience of weight loss has made me far more convinced that weight is actually not under most people’s control.

    First, I started a drug which controlled insulin levels (I’m not diabetic, but for I took it for reasons that are orthogonal to the issue at hand). All of a sudden, I was not thinking about food 24/7. Sitting in front of a piece of cake that I should not have was not an all-consuming mental battle not to eat. I stopped eating when I felt full. I had urges to eat bad food, sure, but they were easily ignored. I also went from being unwilling to get up off a couch for any reason to perfectly happy to exercise. In short, a drug turned me from someone who obsessed about, focused on, and repeatedly binged on food to someone who had a normal appetite.

    I really had no idea it was this easy for people. In turn, I had no idea that my struggle had been something they had no clue about! To this day, I sometimes get wild urges to eat an entire pizza, and realize I forgot my medicine that morning. Anyone who thinks that fat people have the same degree of temptation as thin people (and are just more likely to indulge a passing fancy) is completely, utterly wrong.

    I’ve also had the experience described by the people in the article: in having been fat, my body responds completely differently to food than thin people. In order to lose weight, I did what the people in the article did – exercise up to 90 minutes a day and counted every last calorie. I knew perfectly well that the 3500 calories = a pound number is absolutely not true for everyone. It is an utterly miserable existence. You are entirely focused on food and weight loss, and have remarkably little mental space left for anything else. The two people I know who have maintained weight loss by this method actually switched careers and became physical trainers.

    I could never, ever, ever do this. And if I eat what a normal person eats (as in, 2200 calories a day and according to the food pyramid), I will gain weight on the order of 2-3 pounds a week. Forget about holidays. It is, to me, no way to live a life. I am very very lucky in that I have discovered that I can cut out whole categories of food and initiate and maintain weight loss with no portion control, no counting calories, and a reasonable amount of exercise for someone who has a job and three kids. (For what it’s worth, it’s very high percentage of calories from fat with no grain except rice, no sugar, no processed food, and no seed oils). It is not particularly pleasant or appetizing, and I do go off frequently for holidays and dinners out. But I don’t think about food very much, and am never hungry. I don’t have to expend the mental energy and time that the people in the article do.

    Unfortunately, this approach does not seem to work for everyone. And if it doesn’t, then you’re stuck doing what this couple in the article does. Miserable.

    In sum, I’m pretty sure that I was able to lose weight and keep it off without the devotion of my life to weight maintenance by a couple of coincidences. I no longer consider the obese to lack willpower. As William Blake said, “Those who restrain desire, do so because theirs is weak enough to be restrained.” Maybe not true in all instances, but true in this one.

    • Preach it!

      The other thing I would add here is that the social stigma turn stress of a society that says obesity is weakness or laziness is arguably more physically harmful than the obesity itself (depending on how obese we’re talking). Stress kills. I think that the frame-of-mind has been more beneficial to my health than my actual weight loss was (I’m three years in. I don’t know if I will make five or ten).

  5. I can tell my story, I suppose.

    I was in my early 30’s and “jolly”. 229 pounds. It’s not morbidly obese… but, yeah, it’s chubby. Perhaps even “fat”. I said “you know what? I’m going to change my life and LOSE WEIGHT!”

    I had heard a lot about Atkins and South Beach, I understand, was like Atkins except healthy/sane. Eat all you want… except what you eat has to be on this list here. Fair enough. So the first week I ate all I wanted of the stuff on that list and that list alone. Spinach salads, steaks, cheese for snacks… if I felt peckish, I just made myself a steak. I felt silly and stupid my first day back at the gym after a week of this diet… I was certain that it wouldn’t have worked.

    I lost six pounds.

    Well, I was a believer. I threw myself into it and into my workouts and into my diet and went from losing 6 pounds in the first week to losing about 3 pounds a week for several months. I got down to 195 pounds, lost my belly, gained a lot of muscle mass from the gym, and felt *GREAT*.

    Around 190 pounds, I plateued and was very frustrated by this. I started working out more and started throwing kettlebells. My testosterone *SKYROCKETED*. I was staring strangers down as I walked places. Maribou, bless her heart, was a good sport about some of the side effects (it was like our first year of marriage again!) but I didn’t like the person I found myself becoming. Angry, aggressive (assertive!, my workout partners told me), and sharp.

    I started eating carbs again and watched my old personality fall back onto me like the most comfortable pair of sweat pants in the fat pants drawer.

    I’ve regained the weight (and then a few pounds on top of that).

    I’m also much, much, much, much happier.

    • This is interesting. Its hard to really know what a good weight is for all of us. Most of us are healthy at a weight above what the official recommendations say. Probably happier to

  6. I’ll second what everybody has said. One big issue is how different we all are in our body chemistry and make up. I’ve lost about 60 pounds in the last8 months mostly by the eat better and exercise more strategy. However eat better for me required a sizable change, far more then just slightly smaller portions. Exercising for me is enjoyable and the activities i like to do are hard so they burn a lot of calories. The Wife however has a messed up chemistry so she can eat very well and gain weight. I know my challenges are to keep to decent eating and make fun exercise goals. But for others that wouldn’t remotely work. I can also afford to buy healthier and more expensive foods, which is no small advantage.

    • My wife has struggled more with her weightloss than I have. And anyone that says that she is weaker or has less willpower than I do is utterly insane. When I was *really* trying, I was failing far worse than when I found the right method for me. And if someone else tried my method? It probably wouldn’t work for them. Otherwise I would write a book and make millions. The Magic Cereal Diet, by Will Truman.

      • Are we married to the same woman? Since i have found what works well for me so far, it doesn’t feel much like having to “try” at all. My new habits just feel normal and fine. If it was always an effort i can’t see it working long term.

        I really wonder if woman’s bodies make it harder for them to lose weight.

        • likely, yeah (see studies on exercise and meat intake). plus, the pill.

  7. All I can say is, yes, and thank you, doctor, for allowing yourself to have an eye-opening moment. It doesn’t sound like you had unfair attitudes to begin with, but the article had the same effect on me, and I already thought of myself as being on the “sympathetic” and “informed” side of this question. It’s important to remember the reality of the situation is pretty damn crushing if it applies to you or someone you love, not just someone you are treating or counseling or otherwise problematizing.

  8. A couple of points:

    First, BMI is really just the old, invalidated insurance charts from the 50’s glossed over with **math**. Any measure of weight vs height is doomed to be worthless.

    Second, I don’t see anyone, including Dr Sanders, noting that obseity and health are marginally connected. (You’re more likely to have bad health from your doctor treating your weight instead of your actual problems than you from the weight alone). Fit and fat are not oxymorons, although they are treated as such by most of the media and by a large percentage of doctors.

    • I agree, up to a point. For patients who are overweight but not obese, their health may be largely unrelated to their weight, particularly if they are physically active. Indeed, for most patients of that ilk, I recommend increased physical activity as a goal unto itself, and advise them not to focus on weight loss as a goal.

      That said, for the truly obese, there are a host of both sub-acute and chronic illnesses for which they are at greater risk. Also, the effects of lifelong obesity starting in childhood are poorly understood.

      • And this is where it can get really complicated. Because there is a relationship. Yet as long as society internalizes the correllation, it becomes harder to make being healthy, instead of just being thin (or thinner), a much harder sell. Because people associate their health progress with their weight loss. And without the weight loss, they assume they are making no progress. Discouragement is not conducive to healthy living.

        • the important thing to tell people is that you’ll look better if you put on some muscle. Even if it’s covered by a layer of fat…
          Having just moved house (including the furniture, down four flights of stairs, and up two), I know all too well what that feels like.

        • Morbidly obese is typically defined as having a BMI over 40. Not sure about “truly.” but it’s probably more than 30, which qualifies for obese (except in Singapore, where it’s 27.something).

    • central adiposity is a good correlate to metabolic syndrome, as is overall fat %. both of which are somewhat harder to measure (but my lab did!)

  9. A cocktail of other hormones associated with hunger and metabolism all remained significantly changed compared to pre-dieting levels.

    The sooner we stop viewing humans as agents with free will and start seeing them as bags of chemicals whose internal states are determined by the chemical mixture, the sooner we can really start helping people.

    • That’s an awfully reductionist way of looking at things, James. One can acknowledge the numerous well-described and -understood ways that our physiology and neurochemistry affect our behavior without jettisoning the notion of free will.

      • ya, we can learn to eat volumetrically, or learn that a bit of protein/fat makes you feel fuller.

        • Fiber fiber fiber. In the end (or the beginning, depending on how you look at it), for me, it came down to fiber. Or that fake fiber that everybody swears doesn’t work.

          • FWIW, I actually am willing to concede that the “fake fiber” (I believe you’re referring to inulin?) seems to work, at least in terms of constipation. Lots of patients have reported good response, so who am I to deny it?

          • Inulin and polydextrose. Mostly inulin, when I look at the ingredients.

            It definitely helps on constipation (though, if you ever recommend it to your patients, you cannot stress enough the importance of water – it can be quite painful otherwise). But more than just that. I never had a problem with constipation. Rather, I had a lazy gastrocolic reflex and generally soft and liquidy stool. What fake-fiber did was make my system more regular. While it was building up, I’d not be hungry (allowing me to eat whatever I want, because I’d only eat in small quantity) and after an excavation, I’d be able to eat again (“coligastric reflex”), which I would do, filling me back up somewhat and keeping me in a constant state of regularity. Making me not only less hungry, but feeling better on less food (every other diet had me feeling worse on less food).

      • That’s an awfully reductionist way of looking at things, James.

        Guilty as charged. Yep, I’m that reductionist. That doesn’t mean every problem we face needs a pharmaceutical solution, since lifestyle changes can also affect the proportions of particular chemicals in our body, but I do think that “free will” is just an illusion caused by those chemicals combining in our brains in particular ways.

        I know that’s not a popular view, but I’ve never heard a compelling material explanation for true free will, and I’m a pretty hard-core materialist.

        • I should add that I hold this position tentatively. I’m approaching things from a purely materialistic and evolutionary world view. I can’t grasp how true free will would evolve, so I’m dubious it did. But I have the feeling/experience of free will as much as anyone else, so clearly at least the tendency to feel like we have free will evolved. So maybe actual free will did, too. I can’t claim I really know.

          Ironically, theologically I’m 100% free will. I disdain Calvinism and am devoutly anabaptist. I mean, other than that part about actually believing in God. But if He exists, and if that whole creation/fall story is essentially true, I think it’s quite obvious that God granted humanity free will. Steven Brams even explained it via game theory.

          (Sorry, hope I didn’t threadjack too much. I am strongly supportive of the original thread, so let’s talk about that.)

          • Being a Jew, I don’t believe in that whole “fall” business.

            My feeling is: if we can create emergent behaviors in computers that mimic free will (“Bot wants a blog! Now!”), then we probably have at least similar capabilities.

    • But James, if it isn’t Evil Fat Chemicals that are responsible for my body weight, then what is? It surely can’t be my fault!

  10. I think the most important thing to do if you want to be a thin adult is to make sure your parents are thin. When my parents got married my mother was 5ft 9 and weighed 125 and my father was 6ft 5 and weighed 165. My childhood meals consisted of southern okie food that were mostly fried something, white bread, cheerios with so much sugar on top that you couldn’t see the oats. I gain about twenty pounds every winter and by May it is gone. Another weird thing I do is never buy pants larger than 34. I have busted a few buttons, but eventually, the pants will fit again.

  11. What about these hormones? Give me a ghrelin suppressant and a leptin-peptide YY supplement! Then I’ll feel more full, less hungry, and be able to actually skip a meal without my stomach and small bowel sending chemical text messages to my brain OMG ITS STARVATION CONSUME MUSCLE TISSUE AND CONSERVE FAT IMMEDIATELY! every four hours, the nonsensical effects of which may well be the single best argument against evolution I can think of. Something tells me that minimizing that impulse might help me not eat when I don’t really need to, and thus eat less.

    • I assume that there is a good reason we don’t bottle leptin and put it on the shelf, though I don’t know what it is.

  12. Amusingly, dexter’s method is also the best, most repeatable way of ensuring that you have healthy, cavity-free teeth. Some people, e.g. my husband, can do absolutely minimal things towards dental hygiene (for several years of college, brushing once a month or so, and often skipping days after that) and have about 3 lifetime cavities at the age of 35, all minor.

    And then you’ve got me. My mother describes the teeth she and I share as “lumps of talcum powder lightly coated in enamel.” I got a lot of cavities on a reasonable-to-lazy dental hygiene regimen, so after college I got thorough about it. Flossing after every meal, brushing 2-4 times a day (definitely waking and before bed, and sometimes after consumption as well if I knew I was going a long time between putting food on the teeth), chewing sugarfree gum after every time I put anything but water on my teeth, and cutting sugar almost entirely out of my diet (1-2 ‘sweet desserts’ a month, where ‘sweet’ included things like dark chocolate or a glass of orange juice).

    I started about 2 months before my twice-yearly cleaning; he found some cavities then and filled them. I continued ruthlessly for the next six months, seriously disrupting my life in service to Clean! Teeth!, and at my next cleaning … he found three new cavities, and filled them.

    I kind of despaired at that point and fell back into a reasonable-but-not-scrupulous regimen, like that followed by most adults of my acquaintance, and at my next cleaning, he found 2 new cavities, and one questionable spot that might need some work.

    At that point I felt like punching things, and decided to quit stressing myself out so much over what my teeth were clearly bound and determined to do regardless of my inputs. Yes, I drink soda. With sugar in it. Yes, I eat desserts more nights than not. Yes, I sometimes only brush my teeth once a day (or on bad days, skip it entirely if life is Too Hectic).

    And my dentist still finds 2-4 new cavities every time I go in for my cleaning, twice a year. Some of them end up leading to (because of honeycombed teeth that are more filling than tooth) tooth breakage, crowns, root canals, and so on; some don’t. But I refuse to be ashamed of my ‘character flaw’ anymore, because I just have my mother’s crappy teeth and some people are luckier than I am.

    • My experience kind of proves yours. I’m usually lackadaisical about brushing (although I must do it every morning….I find it hard to even leave the house if I haven’t brushed…my whole day is spent feeling all gunky in my mouth and feeling self-conscious that my breath smells bad), and yet, I have very very few cavities. About a year ago, I went to the dentist after a two-year hiatus (I hadn’t had dental insurance for a while), and she found only one minor cavity.

      • Errr….dangling referent. I’m the one who feels gunky and self-conscious if I don’t brush. I doubt the day has any feeling whatsoever about it.

  13. Something I was wondering: Why is it acceptable to consider smoking dependence (or alcoholism) to have a moral component, but not obesity?

    • It’s not acceptable in any of those circumstances, in so far as it impedes a doctor’s ability to keep his oaths. Considering someone lazy, weak-willed, immoral Leads To Bad Health Outcomes.

      (whether or not it’s true, some truths don’t deserve to be acknowledged)

Comments are closed.