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Earlier this month, the venerable news program 60 Minutes jumped into the roiling conversation about new weight-loss drugs like Wegovy with a segment on recognizing and treating obesity as a disease.

The piece featured real people who’ve tried and failed to lose weight with dieting alone, as well as experts like Fatima Cody Stanford, MD, a renowned obesity physician at Massachusetts General in Boston, and Caroline Apovian, MD, co-director of the Weight Management and Wellness Center at Brigham and Women’s Hospital in Boston. Dr. Cody Stanford told host Lesley Stahl that when discussing weight loss, we should throw willpower “out the window,” and Dr. Apovian said she was grateful to now have safe and effective medications to offer her patients.

Sounds like a fair and balanced report, right? Wrong, said the Internet. In response to the piece, #obesity briefly trended on Twitter. Commenters pointed to Dr. Cody Stanford’s relationship with Wegovy’s manufacturer, Novo Nordisk, from which she’s received payments, which 60 Minutes did not disclose. (Women’s Health reached out for comment from Dr. Cody Stanford and didn’t hear back by press time.)

Commenters’ biggest beef seemed to be with a single quote from Dr. Cody Stanford: “The number one cause of obesity is genetics,” she said. “That means if you are born to parents that have obesity, you have a 50 to 85 percent likelihood of having the disease yourself, even with optimal diet, exercise, sleep management, stress management.” The implication that genetics are wholly to blame for obesity pushed commenters to rage. The cause of obesity is lifestyle, the Internet roared, setting up a two-sided debate that is still ricocheting across social media.

The problem, according to obesity experts interviewed by Women’s Health, is that both camps are…not wrong, but not right, either. “It’s not black and white,” explains Karl Nadolsky, DO, a clinical assistant professor of medicine at Michigan State University. “You do have a 50 to 85 percent likelihood of having the disease if your parents do. But to imply lifestyle factors aren’t important? That’s not exactly true, either.”

Genes, environment, and lifestyle work together to cause obesity.

The truth is obesity is complicated. The research suggests that both genetics and the environment are to blame for the skyrocketing rates of obesity over the past few decades. Not only that, exactly how and how much either factor contributes to obesity can be very individual.

“There’s a very inherent bias against those with obesity that it’s just about willpower.”

For example, there is a spectrum of ways that genetics contributes to obesity. Rare mutations known as an MC4 mutation or a POMC mutation are known to directly cause obesity. But what’s more common is what scientists refer to as “heterogeneous polygenic” obesity, which refers to a cluster of genetic attributes that may predispose someone to weight gain, especially if that person is existing in an environment that encourages weight gain. “Everyone has a different genetic predisposition and environmental aspects to deal with,” Dr. Karl says. “The father of obesity science, George Bray, once made the analogy, ‘Genes load the gun and the environment pulls the trigger.’”

This means that for most people, obesity is a result of a complex interaction of both their genes and their environment or habits. For a long time, it was hard to say how much either genes or lifestyle factors were to blame, but newer genome-wide association studies, which have used sequencing technology to compare genetic differences along with age, gender, physical activity, and diet, have added insight.

“From these data, while we know genetic predisposition is very important to understand and embrace, there is also evidence that increased physical activity and/or nutrition improvements can lessen the effects of the [genetic predisposition] on obesity risk by up to 40 percent,” Dr. Karl says. The bottom line: Genetics contribute significantly, but it doesn’t wholly determine your destiny when it comes to your weight.

Weight stigma makes people believe that lifestyle is by far the biggest contributor when it comes to obesity.

It’s easy for folks to assume that lean people living in our “obesogenic” environment are simply genetically predisposed to leanness, but they have trouble seeing how genetics might also play a role for someone heavier.

When it comes to people in larger bodies, lifestyle is typically the factor they blame—a perfect example of weight stigma, says Dr. Karl’s brother, Spencer Nadolsky, DO, an obesity and lipid specialist physician. “There’s a very inherent bias against those with obesity that it’s just about willpower,” he says. “You’ll see comments on Instagram like, ‘Nonsense, genetics didn’t make you go to McDonald’s.’ But that ignores the pathophysiology of obesity.”

Dr. Cody Stanford said that people with a genetic predisposition to obesity will gain weight even with an optimal lifestyle, which makes it seem like an absolute. The reality is that, “optimal diet and exercise may be difficult to achieve with the genetic predisposition,” Dr. Karl adds. “Hence why even with optimal effort, a significant number will still [have] weight gain and obesity.”

It’s true that obesity involves the brain, as Dr. Cody Stanford pointed out on 60 Minutes (though calling it a “brain disease” arguably wasn’t the best way to put it). Part of what the genetics piece can do is affect the appetite drivers in your brain that tell you when and how much to eat, Dr. Spencer says. “It’s easy for someone who is lean to just say no to certain foods or to stop when they’re full—they don’t have the same appetite signals. They think it’s their willpower, but it’s not.”

(This is also why new weight loss drugs like Wegovy and Ozempic are so powerful. They work by regulating the appetite signals the brain is sending, such that someone who is prone to obesity can more easily change their behaviors, the same way a person with a genetic propensity for leanness can.) Essentially, the idea of “willpower” is experienced by everyone differently, and it’s not shown to be successful for weight loss and management long-term.

Ultimately, this debate is an example of how badly we need to change the conversation around obesity, Dr. Spencer says. “We need to stop blaming individuals and look at the systems,” he says. “We think we’re in control but on a population level, our environment shapes us.”

In addition, while some people have the resources to change what they eat or follow strict lifestyle interventions, many people live in food deserts with limited access to affordable, healthy foods. Their neighborhoods may not be walkable and/or their work schedule may not allow for a workout routine. They may not have access to healthcare or support. Even with all of the above, weight loss is hard. For many, it’s impossible, and can have serious effects, such as depression and eating disorders.

Centering empathy and bodily autonomy is key in this conversation.

In the end, we need a new outlook on obesity—one with much more nuance, Dr. Karl says. Not only do we need to understand the complexity of what’s driving obesity rates on a population level and for individuals, we also need to recognize that weight is not the only health factor that matters. Overall health also includes mental health and positive body image.

While Dr. Spencer argues we shouldn’t downplay the risks of excess weight, ultimately, everyone deserves autonomy to decide how to manage their health, without judgment, discrimination, or misinformation. Newer approaches like powerful drugs that are FDA-approved to induce weight loss should be widely accessible (and covered by insurance) for those who need them, he says.

Likewise, people with bigger bodies shouldn’t feel pressure to diet endlessly—or take any measure to change themselves—if that’s what works best for them. How you achieve health is individual, and for some, that may be more about focusing on behaviors instead of weight.

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