As Diet Ideas Abound, Is Willpower Obsolete?

[Guest guest]

July 10, 2007

Essay

As Diet Ideas Abound, Is Willpower Obsolete?

NY Times

By BARRON H. LERNER, M.D.

When I was growing up, the word “willpower” was used a

lot. If only one was strong enough to resist sweets,

according to logic of the time, one could stay thin.

Yet today, based on a series of scientific

discoveries, the importance of willpower in promoting

weight loss is becoming an obsolete notion. Is it

worth saving?

The concept of willpower came less from scientific

data than from Christian teachings about the dangers

of temptation. Gluttony, after all, was one of the

seven deadly sins, up there with pride, greed,

extravagance, envy, wrath and sloth.

The late 19th century was perhaps the heyday of the

revolt against what C. Burnham, a historian at

Ohio State University, calls “bad habits.” Groups like

the Salvation Army and the Women’s Christian

Temperance Union urged sinners to stop drinking,

gambling and smoking.

Comparable sentiments characterized writings about

obesity. In 1946, G. Smillie, a public health

professor at Cornell, wrote that the physician should

appeal to the obese patient’s “ability to manifest

self-control.” Weight-loss programs like Overeaters

Anonymous and Weight Watchers have reflected this

philosophy.

Similarly, many physicians have also discouraged

surgical procedures like stomach stapling or

shortening of the intestines, not only because of

their risks but also because they were somehow seen as

quick fixes for lazy patients who do not stick to

their diets.

But as critics have pointed out, while willpower can

work, it usually does not. A study published in The

Journal of the American Medical Association in 2005

found that regardless of the diet attempted, patients

lost an average of only 5 percent of their baseline

weight after one year. And dropout rates exceeded 40

percent. [A newer study is reported on this page

today, in Vital Signs.]

As a result, strategies for promoting weight loss have

recently begun to shift from a focus on individual

behaviors to a public health approach.

As the late Dr. H. Gemson of the Mailman School

of Public Health at Columbia once put it, “the causes

of the obesity epidemic are environmental, and the

answers will be as well.” Rather than simply urging

people to eat better and exercise more, experts like

Dr. Gemson have increasingly argued that society has

to facilitate such changes by reducing the

availability of high-calorie foods, advertisements of

junk food to children and reliance on automobiles,

while increasing access to healthy foods and

exercising.

The environmental theory of obesity is prompting

governmental interventions, like New York City’s ban

on most trans fats in restaurant food. And

environmental strategies have successfully been used

in other areas that formerly relied on moral suasion.

For example, taxes on cigarettes have contributed

greatly to lowered smoking rates. Legislatures have

enacted laws making restaurants liable if they permit

drunk patrons to drive home.

So will people necessarily lose weight if society

actively discourages fattening foods? Maybe not.

Consider the genetic hypothesis, the latest

reassessment of the obesity problem.

Research suggesting a strong hereditary predisposition

to obesity goes back several decades, but several

recent findings have put this theory into the

forefront. In 1994, for example, M. Friedman,

a molecular geneticist at Rockefeller University,

discovered the appetite-regulating hormone leptin. Dr.

Friedman believes that people’s appetites are largely

controlled by genetics, which causes them to have

different “set points” at different times in their

lives.

A study in The Journal of the American Medical

Association in May suggested another way in which

genetics might affect changes in weight. Researchers

from Children’s Hospital in Boston reported that

differences in how young adults secrete the hormone

insulin determine how well they respond to various

dietary interventions.

So maybe it is time for health professionals to stop

reflexively assuming that personal sacrifice will lead

to weight loss. But this will not be easy.

For one thing, there certainly are success stories of

people who have dropped dozens of pounds by

drastically altering their lifestyles. Moreover,

watching one’s diet can have beneficial health effects

beyond losing weight.

And I just cannot conceive of a session with an

overweight patient that does not involve a discussion

of being careful at holiday meals, controlling portion

size, avoiding bedtime snacks and trying to exercise

three times a week. Somehow it still seems to me that

part of a doctor’s job is to push patients to try

harder. Just call me old-fashioned.

Barron H. Lerner teaches medicine and public health at

Columbia University Medical Center.