Rethinking Agency in Obesity: it’s Not a Choice

In over 35 years of medical practice, I have yet to meet a patient who conscioulsy chose to be fat.

This is clearly contrary to the popular belief that your weight is under your control and that all it takes is a bit of willpower to be thin. As a consequence of this belief, it is easy to see why failure to control weight gain is widely attributed to a lack of will power or failure to make the right “choices”.

To anyone, even remotely following the complex science of energy homeostasis, the notion that anyone can chose to be whatever weight they want to be just by altering their “lifestyle”, must appear increasingly ridiculous.

Anyone, who is still not “buying it” should probably read the article by Andrew Grannell and colleagues from the University College Dublin, Ireland, just published in Obesity Reviews

In this paper, the authors challenge the idea that individuals are free to choose how much they weigh, and that achievement of long-term weight loss maintenance is just a matter of conscious choice.

As they note, 

“the regulation of hunger, satiety, energy balance, and body weight takes place in subcortical regions of the brain. Thus, hunger and satiety signals are generated in regions of the brain, which are not associated with conscious experience. This points towards biological determinism of weight and challenges ideas of willpower and resultant moralization regarding body weight regulation.”

Accordingly, obesity results from a dysregulation of hunger and satiety, which may in turn result from a wide array of biological, psychological, and environmental causes. 

This understanding of obesity is not only essential in order to counter the continuing misconceptions regarding personal responsibility (which feed the stigma of obesity) but also to recognise obesity as a chronic disease requiring personalized (often life-long) treatment. 

In my own practice I have indeed seen patients display the most amazing feats of will power to try and “conquer” their obesity, only to regain all the weight they lost. Lack of willpower was clearly not their problem!

On the other hand, our increasing ability to pharmacologically or surgically address the underlying subconscious biological drivers of weight gain holds significant promise for the future of obesity treatments, as is documented by consistently superior long-term outcomes with anti-obesity medications and surgery than with behavioural interventions alone.  

This is not because medications or surgery somehow increase “will power” or change the environment or drive a “healthier” lifestyle. These treatments work because they specifically target and change the underlying biology that makes long-term maintenance of weight loss so elusive. 

None of this means that patients with obesity no longer need to take any responsibility for their care. Rather, like people living with every other disease, patients with obesity have the responsibility to seek professional medical advice and to follow that advice (which may include taking prescription medications, seeking out a bariatric centre, showing up for follow-up visits, etc.) to the best of their ability. 

However, it cannot be their responsibility to force their cortex to run their hypothalamus.

Berlin, D