Obesity is complicated — and so is treating it

Many people don’t think of obesity as a disease, but rather as a moral failing. But Dr. Fatima Cody Stanford, instructor of medicine at Harvard Medical School and researcher and practicing physician at the Massachusetts General Hospital Weight Center, points out that obesity is a complex, chronic disease. Stanford’s recent fascinating and informative presentation explains how the body uses and stores energy, and describes the complex interplay of the genetic, developmental, hormonal, environmental, and behavioral factors that contribute to obesity.

Obesity isn’t just “calories in versus calories burned”

Obesity isn’t just about energy balance, i.e., calories in/calories out. “That’s simplistic, and if the equation were that easy to solve we wouldn’t have the prevalence of obesity that we have today,” Dr. Stanford explains. She goes on to say that not only is the energy balance theory wrong, but the focus on that simplistic equation and blaming the patient have contributed to the obesity epidemic. Stigma, blame, and shame add to the problem, and are obstacles to treatment. Indeed, over 36% of adults in the United States have obesity, and the world is not far behind.

She describes her research and experience in the treatment of obesity, including several cases from her own clinic. These are the cases that capture my attention, as they demonstrate most clearly the effects of different treatment approaches (and combinations) to obesity: diet and lifestyle (i.e. behavioral), medications, and surgery. Stanford has seen remarkable, long-lasting positive results with all, but she always emphasizes diet and lifestyle change first and foremost. The program (called Healthy Habits for Life) offered at the MGH Weight Center is a huge commitment, but it can help reframe a person’s relationship with food, emphasizing a high-quality diet, and not calorie-counting.

The components of a successful treatment for obesity

Abeer Bader is a registered dietitian and the lead clinical nutrition specialist at the center. She described the program to me in more detail: it’s a 12-week group-based education and support program with a structured curriculum and frequent contact with patients. The classes are 90 minutes long and led by a registered dietitian, and cover everything from the causes of obesity to healthy eating to debunking popular diet myths, plus recommendations for dining out, grocery shopping, meal prep, physical activity, and more. “The goal of the HHL program is to provide patients with the education, support, and tools to lead a healthy lifestyle.”

The diet they promote is loosely based on the DASH diet and the Mediterranean diet, as these eating plans are rich in vegetables, fruit, lean protein, and whole grains. They use the Harvard Healthy Plate to illustrate a healthy, well-balanced meal.

But it’s also a highly individualized program. “We work closely with the patient to put together realistic goals. I think the most important part of approaching goal-setting and behavior change is to first determine what it is that they would like to improve. Often as providers we tell patients what they need to do, but when you allow the patient to highlight an area that they would like to work on, you may see better adherence,” says Bader.

Other similar comprehensive programs have been shown to help patients achieve lasting diet and lifestyle change, lose weight — and avoid diabetes. The Diabetes Prevention Program helps those with obesity and risk of developing diabetes lose 5% to 7% of their body weight, and decreases their risk of diabetes between 58% and 71%.

As Bader states, “I think it’s important to note that the diet that “works” is the diet that a person will adhere to for the rest of his or her life. We really emphasize the importance of lifestyle change versus short-term diet fix in order to have the greatest success in achieving a healthier weight.” This statement is evidence-based, as a recent review of multiple research studies looking at different weight loss diets found that all worked about equally as well.

Medications to treat obesity

What can surprise people (including doctors) is how helpful weight loss medications can be, though it can take some trial and error to figure out what will work for someone. “These medications affect the way the brain manages the body’s weight set point, and how the brain interacts with the environment. But sometimes there’s no rhyme or reason why one medication works for someone, but another doesn’t.” Unfortunately, as research shows, weight loss medications aren’t prescribed often enough.

In summary, obesity is a complex, chronic disease with many contributing factors. Primary care doctors and obesity specialists can guide treatments that include lifestyle approaches like diet, exercise, and addressing emotional factors that contribute to obesity. For some people weight loss surgery may be an option (a subject for another post).

Selected references

Centers for Disease Control Adult Obesity Facts.

Media and its influence on obesity. Current Obesity Reports, April 2018.

Assessing the evidence for weight loss strategies in people with or without diabetes. World Journal of Diabetes, October 2017.

The Centers for Disease Control and Prevention National Diabetes Prevention Program Information Page: The Research Behind the Program.

Safety and tolerability of new-generation anti obesity medications: A narrative review. Postgraduate Medicine, March 2018.

Low utilization of obesity medications. What are the implications for clinical care? Obesity: A Research Journal, September 2016.

Related Information: Lose Weight and Keep It Off


  1. Gaurav

    Dr. Monique, yeah “Obesity is complicated and so is treating”. But, it’s the most complicated problem in today’s world. There are more and more numbers are increasing and so the treatment should be very effective to avoid this problem.
    In this regard, Jain Ayurveda comes up with “Move Obesity”, the best slimming weight loss capsules & solution to get the best results.
    – Moveobesity.com

  2. Monique Tello, MD, MPH
    Monique Tello, MD, MPH

    Congratulations, Scott, on your success. Surgery plus diet and lifestyle change and possibly medications improve the chances of weight loss and weight loss maintenance. Stay in touch with your team and followup as recommended, so that the weight stays off for life.

  3. azure

    I tried to post a comment regarding research that indicates obesity has been linked to exposure to endocrine disruptors. The comment wasn’t posted. I’m linking to another article and hope the comment is posted. https://academic.oup.com/toxsci/article/76/2/247/1686008

    The above article as well as others, indicates that decreased (or no) exposure to endocrine disruptors (such as pthalates) might decrease obesity rates too.

  4. Allen F Browne, M.D.


    Nice summary of Fatima’s presentation of some modern knowledge about the disease of obesity. For most, it is the energy management system gone awry. And for most, advance tools and a multidisciplinary individualized approach is necessary.

    Keep up the good work. Lack of education and thus knowledge leads to bias and stigma from the public, healthcare professionals, and the patients.

    Allen F. Browne, M.D., Diplomate ABOM

  5. azure

    Omitted from this article is mention of the effects of exposure on development of obesity due to exposure to a variety of human-made chemical compounds. http://www.ciel.org/france-adopts-ban-on-uses-of-bpa-and-dehp/

    “The statement builds upon the Society’s groundbreaking 2009 report, which examined the state of scientific evidence on endocrine-disrupting chemicals (EDCs) and the risks posed to human health. In the ensuing years, additional research has found that exposure is associated with increased risk of developing diabetes and obesity. Mounting evidence also indicates EDC exposure is connected to infertility, hormone-related cancers, neurological issues and other disorders.

    EDCs contribute to health problems by mimicking, blocking or otherwise interfering with the body’s natural hormones. By hijacking the body’s chemical messengers, EDCs can alter the way cells develop and grow.” https://medicalxpress.com/news/2015-09-chemical-exposure-linked-diabetes-obesity.html and https://www.nbcnews.com/health/health-news/more-evidence-chemicals-linked-obesity-diabetes-group-says-n434981

    So why isn’t this blog recommending avoidance of these chemical compounds as part of treatment plans?

  6. Scott

    Dr. Tello. Thank you for this post. I couldn’t agree with you more as to the complexity of treating the disease of obesity. I fought it for 50 years, finally having bariatric surgery last December to help me achieve lasting weight loss and weight maintenance. If only there was really a diet and medication that had the same long-term efficacy as weight loss surgery. While treating obesity indeed requires a multi-disciplinary approach for life, I do wish that bariatric surgery was offered further up the treatment paradigm–especially from thought leaders themselves. That only 1% of eligible patients actually have bariatric surgery in the United States is quite frankly a huge public health failure. Of course this is just the opinion of someone who spent the majority of his adult life obese and who has just lost 110 pounds in the last 5 months!

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