If Thine Eye Offend Thee...

"Has it ever struck you that there's a thin man inside every fat man, just as they say there's a statue inside every block of stone?"

George Orwell

As the national obesity rate continues to creep higher, Cheryl Fuller at Jung at Heart speculates about the deeper meanings, if any, of obesity. As she notes, there is a natural human craving for a smoking gun, a prime mover: a gene, an archetypal childhood experience, a cultural imprint, anything. It is a craving not to be satisfied, as it increasingly appears that weight is a complex result of human identity, no easier isolated and explained than, say, intelligence. It is the outcome of natural (and individually variable) gratification, energy expenditure and environmentally available calories.

Fuller notes that the inferred role of volition is central to obesity, and this combined with its unavoidably public aspect, makes it a virtually unique target of social judgment in our society. Most other objects of discrimination are either agreed to be unchosen (race, gender) or can be more or less concealed (sexual orientation, substance abuse). As a slender person who was fat through adolescence, I have always felt like a bit of an oddity in the great obesity debate. So I thought I would share how my attitudes toward food and lifestyle have developed over time. Crucially, I claim no personal merit or superiority for the experience--it could as easily be said that the weight was lost for me (by developmental genetic change, etc.) as that I lost it and kept it off. And indeed, as I think back on it now, I think that it was not so much an exertion of willpower as it was taking steps to minimize the need for willpower. Or I may have just "grown out of it." But aspects of the process suggest to me what might have to happen for a person to beat obesity.

My family history for obesity is I suppose moderate; some have had it (not morbidly), some haven't. I was basically born fat and remained that way to varying degrees until around age 17. I was not morbidly obese--certainly there were bigger kids--but it was significant enough to affect juvenile social relations, self-esteem, athletics, etc. Especially in my early teen years I went through many diets that were miserable and only transiently if at all successful. But I loved food dearly, a wide variety of foods, and it was painful to deprive myself of things I loved. I heartily disliked exercise, not least because I was out of shape.

When the change came, it came in stages and not as the result of some conscious plan. The first step was my first job at age 15, a newspaper route that, due to the inconvenience of stopping the car every 50 feet, I did on foot and, increasingly, at a run. Suddenly I had daily exercise that I did not have to force myself to do; willpower was removed from the picture. For while I loved food, I also loved having spending money, so I effectively had no choice but to exercise.

I had the paper route for only a couple of years, but I tried to adopt attitudes toward physical activity that would seem automatic, not requiring constant deliberation (the dreaded willpower). I take elevators only to ascend or descend five floors or more. Unless frankly fatigued, I try not to sit when I can stand, and not to be still when I can pace and fidget. I have never much cared for running, swimming, or biking, but found in walking a daily activity that suited my meditative disposition and that eventually came to seem indispensable. I am restless and uncomfortable when unable to take at least a short walk in a day.

But in terms of my psychological stance toward food, I think the more far-reaching change was that, somehow, food ceased to be for me the source of gratification that it once was. This is captured by the cliche "Eat to live, don't live to eat." In a process that seemed to be unconscious at the time, I "decided" that food would no longer be a major source of pleasure to me. I decided that certain foods (pancakes, doughnuts, elaborate desserts) would be largely off-limits to me--they became gratuitous, no longer worth the risk. It helped when, a few years later, I became vegetarian for ethical reasons, a change that in itself dropped the last ten to twenty pounds that I needed.

This has not been culinary asceticism per se. I still love chocolate, ice cream on a summer day, fresh bread, etc. But I no longer relish these things in the sense of arranging my life around them, that is, they are incidental. I will pick them up when convenient, but I don't go out of my way for them and do not relish them in the way that I might relish a piece of music or a book. Food beyond that needed for sustenance is just not a significant part of my life.

As I said, I do not claim any particular merit for this or any implications for any other persons; I merely describe how it seems with me. It is not something that I take smug pleasure in. The point is that it does not require prodigious or prideful effort; it flows naturally. It is well known that genes are not once and for all, that is, they wax and wane throughout the life cycle unpredictably. Perhaps as an adult I merely enjoy some genetic dispassion for high-calorie foods, whereas as a child I suffered the opposite. Certainly I have other vices--on any given day it would be easier for me to forgo food as opposed to caffeine or Internet access.

Alternatively, as Cheryl Fuller might speculate based on her blog post, perhaps it became psychologically intolerable for me to remain fat, such that the joy of eating, long gone from my life, was not too high a price to pay. I think that many people, and certainly not only the obese, delight in food as one of the basic pleasures of animal life and are not willing to give that up. So when a person desires thinness but does not achieve it, it reflects not weakness, but an unwillingness to pay the often steep price demanded. There is a major trade-off involved. And people should not be blamed for their choices (unless they expect others to pay the costs of those choices). The complication is that what appears as a choice may not always be so (does a nicotine addict "choose" to keep smoking? yes...and no). The unsuccessful dieter thinks that he can deprive and exert himself for a few months before reverting to the status quo, when the reality is that he must alter his basic worldview: he must fall out of love with food.

It is often pointed out that eating cannot be considered a true addiction because it is not possible to abstain from eating. That is true, but it is possible to abstain from a certain degree of gratification in eating. To my mind, this is the kind of lifestyle overhaul required to beat obesity, analogous to the alcoholic avoiding bars or hard-drinking friends. While this is a matter of choice, it is not a simplistic matter of weakness vs. strength or willpower. Willpower is the alcoholic sitting in a bar all evening long and not taking a sip--no one expects that to work. One cannot avoid food, but one can avoid food as pleasure. Just as an alcoholic must look at a bottle and see poison, someone wishing to lose weight must look at food and see not a sumptuous feast, but rather a necessary evil. And obviously it is crucial to construct compensatory gratifications, whether sensuous or intellectual.

Big Deal

"If you hate violence and don't believe in politics, the only major remedy remaining is education."

George Orwell, "Charles Dickens"

In last month's Atlantic Monthly, Marc Ambinder usefully reminded us of the complex and multifactorial causes of obesity, and therefore the oversimplicity and unhelpfulness of the traditionally stigmatizing, "willpower" approach to weight loss. After all, when we consider the epidemic of fat in this country (and increasingly in prosperous nations generally) in recent decades, it isn't human nature that has changed, it is context that has changed. Our thinner grandparents didn't stay thin by means of virtuous self-renunciation; they had no other choice.

Ambinder documented now well-known social factors--sedentary residential and work environments coupled with high caloric content of foods (especially those hawked to children, the poor, and minorities)--acting in tandem to foster obesity. And he made the important point that it is more and more the case that "going with the flow," that is, eating what the Joneses eat, and doing what comes "naturally" in our highly artificial environment, will in fact make one fat. For most of our evolutionary history, becoming fat required either heroic effort or terrific good luck. In contemporary society, remaining thin requires either remarkable discipline or genetic good fortune. This brings to mind Nietzsche's point that many are virtuous merely through timidity.

In decrying the still popular tendency to demonize the obese, Ambinder made the point that in the end, stigmatization just doesn't seem to work very well. Would obesity be even more prevalent if there were no stigma whatsoever, or if fatness were actively celebrated? Well, probably, but at least when it comes to eating behaviors, the extraordinary rise of obesity in recent decades despite active stigmatization suggests that the latter stops working at a certain point. One wonders if such a point might be somewhere around the point at which the majority of people are overweight--it is simply hard to stigmatize the majority, it seems to me.

One can push individual responsibility only so far, to the point where the general outlines of mysterious "free will" can be said to lie. Beyond this point, why even speak of some kind of nebulous "free will" that is supposedly going unexercised in some malfeasance of bad faith? If people endure discomfort, ill health, shame, and stigmatization and still do not lose weight, why pretend that they could if they only tried harder?

Ah, this is where it gets tricky. Ambinder acknowledged that in experiments or other settings where people have (voluntarily of course) been put into extraordinary low-calorie and high-exercise environments for extended periods of time, they lose weight of course. Similarly, if one could pay people $1 million per pound lost, the obesity rate would shrink rapidly. Holding a gun to someone's head will help them to make wiser dietary choices. In this sense, obesity is not like cancer, which does not respond to similar incentives.

But unfortunately perhaps for human nature, numerous studies have shown that even most people who do succeed in losing large amounts of weight only rarely keep it off. That is because in our society of abundant calories and minimal necessity of exercise, and in the absence of genetic luck, it requires heroic effort to lose weight and keep it off. That's where human nature comes in; for the most part discipline and consistency are, by definition, average and not heroic.

This brings me back to the Orwell essay, in which he argued that Dickens perpetually urged a revolution in individual moral behavior rather than a reconsideration of social systems and incentives. Orwell suggested that while such urging has a radical aspect (a reimagining of human moral capacity), it also can be a deeply conservative, implicit embrace of the status quo, for when has human nature ever changed from the ground up and in a spontaneous fashion?

But consider Orwell's three-part approach of education, politics, and violence for social change. Inasmuch as childhood obesity is a significant root of the epidemic, then education about nutrition and exercise, a la Michelle Obama's campaign, can play a major role. Politics could reduce the influence of food advertising, influence consumption via taxation, and increase options for safe and convenient exercise in residential and urban locations.

By violence Orwell meant of course social unrest (assassination as the ultimate force for cultural change), but it occurs to me that violence could also refer to, say, bariatric surgery, of which Marc Ambinder openly proclaimed himself a successful beneficiary. If fat is the enemy, then by all means pressure people to fend it off themselves, and create the conditions in which they can best be motivated and educated, but beyond a certain point, stop waiting for mythical humans of superior willpower. Just cut out the fat, figuratively speaking. Kill it, and thereby begin to transform human nature itself. In that sense all technology is violence, altering the material context of human experience.

Willpower

"During these last decades the interest in professional fasting has markedly diminished. It used to pay very well to stage such great performances under one's own management, but today that is quite impossible. We live in a different world now."

Kafka, "A Hunger Artist"

Of all issues perhaps obesity best embodies the complex, perhaps unfathomable relations between the "willing spirit" and the "weak flesh," as the saying goes; this is all the more true now as obesity, as compared to drug or even alcohol problems, has affected a large fraction of the population. This week's New England Journal of Medicine features a telling large-scale diet study, with an accompanying editorial (the latter is brief and particularly worth reading for general interest).

The study, conducted by Frank M. Sacks, M.D. et al, followed 811 adults over two years and looked at the weight loss resulting from diets containing varying ratios of protein, fat, and carbohydrates. It was an intensive program involving relatively affluent and enthusiastic adults as participants and experienced nutritionists and other weight-loss experts who provided counseling and support.

Unsurprisingly, subjects did not uniformly comply with the dietary ratios and caloric guidelines, but even so the study concluded that the protein/fat/carbohydrate breakdown was not a significant predictor of weight loss (a result that in a rational world would end a thousand fads, but in the real world will have little effect on the weight loss industry). Among the impressive 80% who completed the study, average weight loss at six months was 6 kg (7% of starting body weight), but the weight crept back slightly such that average loss at two years was 4 kg (about 9 pounds of course). The most significant predictor of success? Attendance at counseling and support meetings; in other words, motivation matters.

While 9 pounds is better than nothing, the discouraging overall conclusion (corroborated by many previous weight loss studies) is that on average, diets do not work. Indeed, in the editorial Martijn B. Katan, Ph. D. writes, "Evidently, individual treatment is powerless against an environment that offers so many high-calorie foods and labor-saving devices," and he goes on to emphasize community prevention initiatives that may, barring bariatric surgery, be the only viable intervention. However, "on average" is important, because if one considers that many subjects lost no weight at all, a number of them lost a substantial amount and did keep it off for two years.

As a general philosophical point, it seems reasonable to conclude that those suffering from obesity, somewhat like those in thrall to substances of various kinds, are not (yet) sufficiently motivated to change their behavior. This to me seems like a statement of psychological fact, and is not meant to be remotely disparaging. It is not to say that they are "weak," that they are "happy" about their obesity or that they don't want (at all) to change their dietary and exercise patters; it is merely to say that these motivations are not sufficiently vigorous to change behavior, or they conflict with other motivations. The biochemistry of weight loss is not hard--reduction of caloric intake and increase of caloric expenditure beyond a certain point will result in weight loss, as surely as an apple falls from a tree; it is the psychology of weight loss that is hard.

We increasingly know from evolutionary psychology that the biological hurdles are high for dieters--we are wired to find fats and carbohydrates highly reinforcing, and they are abundantly available in contemporary environments. We are similarly wired to conserve energy and avoid unnecessary exertion. Versus these factors, the disincentives of obesity, except in its most morbid forms, are somewhat abstract and distant; the health effects are often years off, and the social stigma of obesity is often surmountable and may even be decreasing as obesity becomes less uncommon. And while I don't mean to psychopathologize obesity or to make blanket statements, in some cases that problems with self-esteem may curtail the emotional reward of successful weight loss.

Also, we know that diets are much easier in the short term than in the long term. The improvements in physical well-being and appearance that accompany dieting tend to be subtle and incremental. Someone who can stop abusing alcohol or cocaine may feel remarkably better within days, whereas a dieter may not feel or look significantly different for months.

As mentioned, the editorial concludes that once we talk about the treatment of obesity, as opposed to its prevention in the first place, the battle is already mostly lost. At this point that may be true in a general epidemiological sense, but I keep thinking about those few who do get it off and keep it off. The point is not at all that they are "better" or "stronger" than anyone else; rather, in the context of their life narratives their resolve exceeded a critical point because the payoff somehow became worth it to them.

I don't know that there is a simple recipe (so to speak) for getting to that point, although a recent local news story I saw floated the idea of higher insurance premiums for obese state employees (as well as smokers). It would be a bit disheartening if that made the difference, but that's because I'm more of an existentialist than a behaviorist by nature. The means shouldn't matter.