Is it right to push the overweight to shed their excess fat? In spite of the many strong and simplistic opinions that continue to be loudly expressed on this question, it is actually a charged and complex one that deserves some careful and nuanced consideration.
First of all, ought we as a society or as individuals have any say in what sort of weight it’s OK for others to carry? The arguments from one side: As Sarah Palin puts it, it is among our “God-given rights” to be obese; it may not even be as bad from a health perspective as everyone makes it out to be; and besides, the overweight are typically powerless to do anything about it, so why make them feel bad about it? From the other side: Obesity is, according to a wealth of evidence, a major health crisis that affects all of us, in that the burden that obesity-related disease places on the health-care system raises everyone’s health-care costs; obesity is associated with lower productivity that hurts the economy; and the prevalence of obesity makes it more likely that children and others will become obese, because as social creatures we closely influence one another.
Does pushing the overweight to lose weight even accomplish anything? On one side: The overweight already want to lose weight, and many have tried desperately to do so, so giving them grief about it only makes them feel worse, and in fact it tends to be counterproductive. On the other side: Many of the obese aren’t working at diet and exercise, and may not even see their or their children’s excess weight as much of a problem, suggesting there’s room to usefully raise consciousness; and doctors, public-health officials, early education providers, loved ones and close friends, at least, can’t be expected to stay mum as people they care about or are to some extent responsible for remain on a collision course with obesity-related disease.
Is losing weight simply a matter of taking responsibility for one’s behavior? On one side: Anyone can lose weight–just eat less and exercise (or do whatever magic one-size-fits-all solution you believe in, be it cutting carbs, or cutting fat, or drinking water, etc.). On the other: It’s in the genes, and diet and exercise won’t fix it.
My own take on these questions:
· I think it’s absolutely fair for any of us to get involved in encouraging the overweight to lose weight, because of the hard and soft costs to society. It’s real money, it’s our money, and it affects our children.
· I think attempts to push the overweight into losing weight are frequently ineffective, harsh and stigmatizing, and that’s just unfair, unreasonable and even cruel. We ought to only push in certain, careful, helpful ways, and only so far. Instead of being confrontational and critical, especially on a personal level, it’s much more reasonable and helpful to make changes in society that will make sure everyone gets the right messages about health, and is prompted to eat healthier food and become more active. We can make these changes in schools, in the workplace, in foodstores, and in the media. And we can make more and better behavior-change resources available for individuals and families. At the same time, we need to stop muddying up the picture with the sort of distorted messages that encourage people to either downplay the problem of obesity or to think that fad diets, excessive exercise, surgery or pills can fix it.
· I believe most people who are significantly overweight, with some exceptions, can lose weight and become far healthier by changing diet and becoming more active–they are absolutely not doomed by genes, in spite of all the anecdotal evidence and highly flawed studies that are held by some to suggest otherwise. But that’s not the same as saying the overweight need to get on the ball and fix themselves. It’s clearly extremely challenging for most people, overweight or not, to simply cut way back on their calories or take up intense exercise regimens and then maintain the weight lost that way–our bodies and brains fight that sort of traumatic intervention with everything they’ve got. But if we can fix the environment and otherwise help the overweight into making a series of relatively small, gradual, easy-to-live-with changes that become lifelong habits, most overweight people will benefit from it, and without having to submit to futile self-torture. If our involvement takes the form of assistance and encouragement and support, then we can help make a difference instead of merely being nasty gadflies. That attitude puts the blame for obesity where it belongs: on all of our shoulders.
I know many and probably most overweight people simply want to be left alone about it. But I don’t think we’re obligated to respect that wish–not if it’s a condition that affects all of us. Let’s just make sure we’re being reasonable, respectful, caring, wise, and helpful about the sorts of tactics we bring to bear.
David H. Freedman 
So if getting obese people active is part of the goal, why aren't companies who require their employees to sit at desks for eight hours also required to provide personal trainers and an exercise facility? When concern about obesity and diabetes is so high, why don't doctors stop with the advice about taking up walking and dieting and instead prescribe physical therapy that would provide obese people with exercise skills in a more compassionate, assisted environment designed to change their habits?
The question of what businesses could or should do about overweight employees is a complex one, especially when it comes to thinking in terms of forcing companies to do something. I do think it's a very important question, and I'll be addressing it in coming posts and articles. I will say here that businesses interested in helping their employees to be more fit probably ought not to focus on personal trainers and gyms. In terms of establishing lifelong healthy habits, people are much more likely to stick with simple, moderate walking routines than they are with any sort of formal, fitness-center-based exercise regimen. What I'd like to see companies do is encourage employees to do some walking during the day, and make it easier for them to do it. Not only would that be more effective than gyms and trainers in the long run, it would be cheaper. Of course, it would be great if companies additionally provided fitness facilities and personal trainers for employees who truly enjoy more ambitious forms of exercise, but I don't see pushing companies to do it. Doctors certainly should be dealing with patients' needs for more activity in a compassionate, assistive way, and if your doctor is treating you differently you really ought to consider switching doctors. (Some small minority of people appear to respond well to bullying and harsh and insensitive treatment, of course, so I guess there might be exceptions.) But again, I think physical therapy, at least in the sense of the term that means working with a professional on certain exercises and usually with particular equipment, is overkill when it comes to obesity. I'd like to see doctors encouraging their patients to do modest amounts of daily walking, and to start adopting healthier eating habits, not to hit the gym and severely restrict calories. Most doctors aren't much trained in behaviorism, so the best thing most doctors could do for their overweight patients is help them get connected with a good behaviorally oriented weight loss program. And companies could be helpful in that regard, too, as long as they did it in a way that wasn't insensitive or overbearing. For example, companies could perhaps make it less likely that overweight employees would feel singled out by a get-walking and eat-healthy program if it were aimed at all employees regardless of weight and fitness.What we need to get as far away from as possible is the exercise model given us by The Biggest Loser, where overweight people are pushed boot-camp-style into extremely punishing levels of exercise, not to mention starvation diets. Not one out of a thousand people could possibly adhere to that sort of oppressive exercise regimen over decades–which is why (as far as I can tell) former contestants typically seem to put the lost weight back on, in spite of all the extraordinary incentives they have to keep it off, such as knowing they'll be back in the spotlight at some point for all of America to cheer or jeer.
I read your recent post with some hesitation. As an obese medical student I can see both sides of this argument. On the one hand the negative effects of obesity on health are becoming clearer to me and I can see that encouraging people to lose weight is important, but having sat on the other side of the doctor's desk I see so often how badly this is done. So often I see doctors use the "tough love" technique and I cringe internally. I cannot tell you how awful it feels to have an obstetrician tell you that because you are overweight you have "lost the right" to have a baby. (This was not encouraging or helpful at all). It is an issue that I struggle with in my own dealings with patients as many have completely unrealistic expectations placed upon them by well meaning doctors. I agree that workplaces could go a lot further in investing in the health of all their employees, not just the overweight ones. Sitting at a desk for 8 hours a day, staring at a computer screen and then to add say 2 hours travel time is not good for anybody. So often the food offered in workplace cafeterias very unhealthy (even in hospitals) and most white collar workers would be lucky if they got more than 10 minutes a day in sunshine and open air. I agree that it would be great if more companies started health campaigns for all their employees and would be very interested if you knew of any that had been shown to be effective.The medical course that I am in is starting to teach how to teach behaviour change and how to effectively encourage patients to stop smoking, reduce weight etc. However, from what I have observed from amongst my peers, many soon-to-be doctors believe that people who are overweight are just lazy and if they just "got off their asses", as one charming colleague put it, they would soon lose those pesky extra kilos and soon be down to their ideal weight. Until this mentality amongst the medical community is changed I don't think there will the the required compassion and assistance. It was very interesting (and incredibly disheartening) to read the comments to the Medscape article a few months ago about the appointment of a new overweight surgeon general in the US and the response of the medical community.