Yes, for any other other condition it would, but in the case of weight loss everyone knows that if people just ate less and exercised more they could be as thin as they like. People who are obese have chosen to be obese. Ultimately, it's a moral issue -- fat people who remain fat are undisciplined and unwilling to take responsibility for their behavior. Those test results merely show that 90% of fat people fit into this category.

I can't think of any other condition where we take this stance. What, that new chemotherapy is effective only 10% of the time? What the hell is the matter with those lazy slobs with cancer, why don't they get on the ball?

That would be absurd, of course. By and large (putting smoking and a few other lifestyle choices aside) cancer doesn't have the same behavioral component as obesity. There may be as many physiological components as behavioral in the 90% (or greater) failure rate for those who have tried to cure their obesity via diet and exercise, and/or those behavioral components may be just too hard for most people to get under control. With obesity, there is an assumption of choice. This may, in fact, be an illusion of choice.

It's hard to say whether choice is an illusion, because these studies don't say why diet and exercise fails; they merely show that -- for most people, most of the time -- it is not a successful long-term cure for obesity. However, when you put that body of evidence up against a powerful meme like "Diet and exercise constitute a universal cure for obesity for anyone willing to make a few long-term lifestyle changes," the sparks start to fly. Everybody knows we could all be thin if we just tried hard enough, so don't go rocking the boat with your scientific evidence. Some of the more arrogant commenters to Dean's post have assumed (not suggested, which would have been sufficiently rude and off the point) that he is making this argument in order to excuse his own obesity. The data shows what it shows irrespective of the weight of the person making it. (And btw, I have never seen Dean and have no idea whether he is, in fact, overweight.)

But just by way of full disclosure: long-time Speculist readers will know that I have battled obesity all of my adult life. A couple of years ago I chronicled a doctor-supervised diet-and-exercise program in which I lost about 70 pounds. I hit a long plateau and eventually stopped reporting on my progress -- there was nothing to report. Since then I have regained about 20 pounds. If I can keep my weight at my current level, 50 pounds down, for three more years I will be one of those statistical anomalies Dean is talking about, part of the 0.1% - 10% of the population who can keep 40 or more pounds off for more than five years.

So nobody start any of that "making excuses" crap with me. I thoroughly intend not to be obese in the future, and to find a long-term solution.

However, since the odds are against me with the approach I've been using, and -- even if I do make it work, it will likely continue to be an ineffective approach for 9 out 10 people -- it's fair to inquire as to whether there aren't any alternatives to D&E (diet and exercise) as a long-term cure for obesity? One reason I believe that the D&E meme has such a strong hold is that there are so few alternatives. But there are some, and others are beginning to surface. Let's review a few:

Modified D&E

Hey, just because something hasn't worked in a hundred years or more of trying, that doesn't mean it can't work. No doubt there have been a lot of variations on D&E in more than a century of research, but then again it took Edison quite a few tries before he found a good working lightbulb filament. One of the big objections to Dean's interpretation of the data is thermodynamics. There must be a level of diet and exercise that would make anyone thin, no matter how low the individual metabolism. After all, if you stopped feeding someone altogether, he or she would die of starvation, right?

But the fact is that people find it very difficult to stay at the level that keeps the weight off. Maybe we should be looking not just at the mechanics of burning calories, but at the drivers that make us want to eat or want not eat, and how effectively our bodies burn calories.

One of the most intriguing diet books to capture popular attention in recent years is The Shangri-La Diet, in which author Seth Roberts describes a methodology of taking in non-flavored calories each day as a means of both suppressing appetite and lowering set point -- the metabolic target weight that one's body attempts to achieve and stay at. I'm personally giving this diet a second try right now. I tried it for a few weeks after the holidays and didn't find it terribly effective. I recently picked the book up again and decided to give the process a longer go -- say 3-6 months -- before deciding whether there's anything to it.

However, even if Roberts' methodology doesn't work for me, I think he's on the right track. These are two things that need to be addressed to make a D&E program effective for more people.

Another book that I bought at the same time is the TNT Diet. This book outlines the exercise program that Stephen is currently following. The TNT program places a lot more emphasis on building muscle than it does on "burning calories." Muscle is an important factor because it naturally ups the metabolism and it provides weight on the body that isn't fat. So even if my set-point was 250 pounds, and that was my body's final answer on how much it wants to weigh, I could weigh 250 pounds looking like this:

rather than like this:

(although I was closer to 300 at that point.)

I think we will see a lot more of these kinds of approaches in the years to come (as we have in the past few years.) Most of them will turn out to be dead-ends, but hope springs eternal that we will find a variation on D&E that will be more effective for more people.

Surgery

Wikipedia reports that 140,000 gastric by-pass operations were performed in 2005. Personally, I would rather be fat than go through that procedure. And, in fact, I would have to gain weight for it even to be an option -- it's only for the morbidly obese, i.e., those with 100 pounds or more to lose. The Wikipedia article doesn't say what the long-term success rate is for gastric by-pass surgery, but I'm betting it's considerably higher than one in ten.

I think it's safe to predict that the future will provide less drastic and safer surgical approaches to obesity than we have today. Certainly, today's gastric by-pass options represent a major improvement over the variations that were available in the past. Still, I can't imagine any changes to by-pass surgery that would make it attractive to me personally. I'm looking for something more in the line of an appetitendectomy.

Drugs

Wikipedia lists six anti-obesity drugs:

Orlistat
Sibutramine
Metformin
Byetta
Symlin
Rimonabant

As with surgery, drugs are only prescribed for the morbidly obese. It's interesting to note what exactly it is these drugs do:

Anti-obesity drugs operate through one or more of the following mechanisms:

-- Suppression of the appetite. Epilepsy medications and catecholamines and their derivatives (such as amphetamine-based drugs) are the main tools used for this. Drugs blocking the cannabinoid receptors may be a future strategy for appetite suppression.

-- Increase of the body's metabolism.

-- Interference with the body's ability to absorb specific nutrients in food. For example, Orlistat (also known as Xenical and Allī) blocks fat breakdown and thereby prevents fat absorption. The OTC fiber supplements glucomannan and guar gum have been used for the purpose of inhibiting digestion and lowering caloric absorption

Anorectics (also known as anorexigenics) are primarily intended to suppress the appetite, but most of the drugs in this class also act as stimulants (dexedrine, e.g.), and patients have abused drugs "off label" to suppress appetite (e.g. digoxin).

I wouldn't be too keen on taking any of these, but I find it very interesting that increasing metabolism and suppressing appetite are both addressed by drugs. These two factors do seem to be a key part of the overall picture, even though D&E purists don't want to acknowledge the role they play.

Gene Therapy

The ultimate long-term obesity treatment may involve gene therapy. Ray Kurzweil explains:

One gene we’d like to turn off is the fat insulin receptor gene, which tells the fat cells to hold on to every calorie. When that gene was blocked in mice, those mice ate a lot but remained thin and healthy, and actually lived 20 percent longer.

What a great idea. Just tell your body to stop making fat. Here we have a treatment (in mice) that not only promises a potential long-term solution to obesity, it apparently brings along for the ride some of the life extension benefits of caloric restriction. Be thinner, live longer. Sounds like a pretty good deal to me.

I think this sort of treatment will be slow to catch on, however, primarily because the D&E meme has instilled a reluctance to allow legitimacy to anything but the "thermodynamic" approach. Weight loss achieved and maintained through genetic manipulation is not earned in the same sense that weight loss achieved through diet and exercise is. Many critics are highly moralistic in their approach to this issue, condemning the obese who can't make a go of the D&E approach for their lack of discipline and personal responsibility.

Still, I think that a treatment such as this will be hard to stop. After all, we'll only be catching evolution up to modern reality. We evolved that particular gene to make sure that we could store enough energy to last until the next successful hunt. Today, we don't need bodies that are so good at storing fat. In fact, we would benefit tremendously from having bodies that aren't nearly as good at storing fat.

I don't know which approach will win out in the end, whether modified D&E will provide sufficient means of appetite suppression and metabolic increase, or whether having one's insulin receptor gene adjusted will be as common as having one's teeth cleaned is today, or whether some new surgical technique will provide the ultimate safe and efficient solution to the problem. But I am thoroughly convinced that our range of choices in dealing with the problem of obesity will be much greater in the near future than they are today, and that the future success rate for dealing with the problem will be well north of 10%.