You probably know that I've been in conversation with Dr. Christopher Ochner, and this is probably the last installment in that conversation. I expect we'll continue to be in touch, but this exchange has been pleasingly unusual and I don't know that we'll approximate it. Please give Chris a hand for engaging on these points. I am.]

By Dr. Christopher Ochner

Have to admit, I’m incredibly captivated by Michael’s journey and, even more so, by his insight and candor in describing it.  If I ever dislodge my nose from the spine of a medical journal, I’ll give Fat Boy Thin Man a whirl.

I’m with Michael right up to the assertion that I’m “giving lifestyle choices a free pass.”  In terms of treatment, I believe responsible lifestyle choices to be necessary but not sufficient for the majority of obese individuals.  Regardless of what worked for any one individual, the unfortunate fact is that the average adult individual who has been obese for a period of time has less than a 1 percent chance of maintaining a healthy body weight long-term.  

In terms of etiology, it becomes necessary to distinguish between what causes obesity versus what maintains obesity. First off, we are all biologically predisposed to becoming obese in an obesogenic environment, with only about one-third of us able to resist. That said, I believe that the vast majority of individuals have the ability to not become obese, with lifestyle choices accounting for a hefty percentage of the variance in body weight (lifestyle choices making a large if not the largest difference in determining who remains lean and who develops obesity).

Put simply, the choices we make about nutrition and physical activity largely determine whether we remain lean or become fat.  However, once an adult has developed and maintained obesity for an extended period of time (varies but probably about 12 months), the body adopts that new higher body weight and will from then on defend that body weight as if it needs every one of those pounds to survive. (see Ochner et al., 2013 for an overly complicated explanation).  At this point, biology takes pole position and, for the vast majority of individuals, all the willpower and support and behavioral techniques are not sufficient to overcome the biological drives to maintain an individual’s highest sustained weight.

Regardless of Michael’s humility in insisting that he’s not special, he is a statistical unicorn.  Less than 1 percent of obese adults are able to achieve what he did and sustain it long-term. By definition he is very special indeed.  So, unfortunately, we haven't been able to teach other individuals to follow his example, but not without trying.  Hard.

The implication of Michael’s position is that each individual is responsible for his or her body-mass destiny and it is, therefore, the individual’s fault for not being able to regain and sustain a healthy body weight. In fact, what we (the “experts”) have been offering them for the past 20 years (i.e., “eat less and move more”) is just plain insufficient to overcome the potent biological drives to restore an individual’s highest body weight.

Myself and a few deservedly prominent figures in the field of obesity just submitted consensus statement addressing this exact issue and the unfortunate prominence of this opinion among even clinicians and educators. The assumption that lifestyle change alone should be sufficient is at best incorrect and may in fact have adverse consequences. The expectation that individuals should be able to simply change their eating and activity habits to achieve and sustain a healthy body weight perpetuates the stigma that individuals with obesity are lazy and lack willpower. This expectation also may increase feelings of failure and negative affect in individuals with obesity, which have been shown to lead to further overeating.

Being disconcerted with the idea of people not “having to” give up their favorite foods makes the presumption that people will do what you tell them to do.  If that worked we wouldn’t be having this conversation; I would be doing something more lucrative b/c there would be any need for obesity researchers.  I’d tell people to stop eating crap, they would do it, and everyone would be happy.  It’s not as if obese individuals just don’t know that raw spinach is healthy and jelly doughnuts are not. There is literally no healthy diet that can be prescribed that more than a few percent of people are able to stick to.  In fact, the only diet that most people seem to be able to stick to is the American diet — this teaches us that people are going to eat the foods they love to eat regardless of what you tell them or how you say it.  That is why I would rather teach individuals how to make the foods they love more healthy rather than try to convince them not to eat them — we already know the latter doesn’t work for 95 percent to 98 percent of the people out there.

Take Home Points: Health at Every Size movement has been debunked — no such thing as healthy obese. I do not believe that individuals are "stricken with obesity," having no control over the situation.  Individuals' choices are largely responsible for the initial development of obesity but the factors that cause versus maintain obesity are very different.  Once someone has been obese for some time, the confluence of a number of extremely potent weight-maintenance mechanisms readily override even the most legitimate of attempts to will past it — for all but very few exceptional individuals.  My concern is the common assertion that individuals with obesity deserve it because they are weak-willed and they all sit a McDonald’s every day inhaling extra-value meals and then proceed to proclaim that every diet out there has failed them.  I have a problem with the ‘just eat less and move more’ mantra that pervades amongst clinicians & educators, those who are supposed to know better.  I have a problem with the assumption that individuals should just be able to simply adopt a healthy lifestyle sufficient to be lean.  To be on par with your never-obese lean individual, this would mean their making significant changes to metabolism, neural dopamine levels, neural responsivity to food cues, gut-peptide profile and adipocyte count.  Until we figure that out, I’d rather not blame those in the situation for being there — that really doesn’t provide them any kind of road map to find their way out. Responsible or not, they need help that doesn’t come in form of societal disgust and judgment.  Even though they may be 100 percent responsible for getting there, I would take issue if the majority of healthcare providers decided that simply telling them to stop eating so much and looking down on them should be sufficient. The goal is not to place blame, the goal is to find something that can help a lot of people who desperately need it.

Reference for the Really Sciencey Stuff: Ochner CN, Barrios D, Lee C, Pi-Sunyer FX. Biological Mechanisms of Weight Regain following Weight Loss Diet in Obese Humans. Physiology & Behavior 2013;120:106-13.

The main concept from this article was featured on "World News Tonight" with Diane Sawyer on Oct 8, 2013, and the manuscript itself was featured on New York One (NY1) news on Dec 13, 2013. Dr. Ochner would be happy to send a PDF reprint of this article upon request: christopher.ochner@mountsinai.org.