Editor’s note: Part 1 of a six-part USA TODAY series examining America’s obesity epidemic.
Barbara Hiebel carries 137 pounds on her 5-foot-11 frame. Most of her life she weighed 200 pounds more.
For decades she tried every diet that came along. With each failure to lose the extra weight or keep it off, her shame magnified.
In 2009, Hiebel opted for gastric bypass surgery because she had "nothing left in the gas tank" to keep fighting. She quickly dropped 200 pounds and felt better than she had in ages.
Over the next eight years though, 70 pounds crept back, and the shame returned.
"I knew everything to do to lose weight. I could teach the classes," said Hiebel, 65, a retired marketing professional from Chapel Hill, North Carolina. She asked to be identified by her first and maiden name because of the sensitivity and judgment surrounding obesity. "I'm not a stupid person. I just couldn't do it."
The vast majority of people find it almost impossible to lose substantial weight and keep it off.
Medicine no longer sees this as a personal failing. In recent years, faced with reams of scientific evidence, the medical community has begun to stop blaming patients for not losing excess pounds.
Still, there's a lot at stake.
Obesity increases the risk for about 200 diseases, including heart disease, diabetes, asthma, hypertension, arthritis, sleep apnea and many types of cancer. Obesity was a risk factor in nearly 12% of U.S. deaths in 2019.
Even for COVID-19, carrying substantial extra weight triples the likelihood of severe disease.
Early in the pandemic, pictures from intensive care units repeatedly showed large people fighting for their lives. At Weill Cornell Medical Center in New York City, the average age for ICU patients was 72 if their weight was in the "normal" range and just 58 if they fit the medical definition for having obesity, said Dr. Louis Aronne, an obesity medicine specialist there.
As fat cells expand, the body produces inflammatory hormones. Combined with COVID-19, the inflammation creates a biological storm that damages people's organs and leads to uncontrolled blood clotting, Aronne said.
The link between obesity and severe COVID-19 is surprisingly strong, said Dr. Anthony Fauci, who has dedicated his life to combating infectious diseases.
"The data were so strong," Fauci said of a recent government study. Even for children, every increase in body mass index led to a greater risk of infection with COVID-19 and for a dangerous case of the viral illness.
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"The more you learn about the deleterious consequences of obesity, the more reason and impetus you have to seriously address the problem," Fauci said.
But despite more than 40 years of diets and workouts, billions of dollars spent on weight loss programs and medical care, and tens of millions of personal struggles like Hiebel's, the obesity epidemic has only gotten worse. Nearly three-quarters of Americans are now considered overweight, and more than 4 in 10 meet the criteria for having obesity.
To try to understand why, USA TODAY spoke with more than 50 nutrition and obesity experts, endocrinologists, pediatricians, social scientists, activists and people who have fought extra pounds. The reporting resulted in a six-part series, which explores emerging science and evolving attitudes toward excess weight.
The experts pointed to an array of compounding forces. Social stigma. Economics. Stress. Ultra-processed food. The biological challenges of losing weight.
They agree people need to take responsibility for eating as well as they can, for staying fit, for sleeping enough. But simply promoting individual change won't end the obesity epidemic – just as it hasn't for decades.
It's time to rethink obesity, they said.
Experts offered different ideas to change the trajectory.
Subsidize healthy food. Make ultra-processed foods healthier or scarcer. Teach kids to better care for their bodies. Provide insurance for prevention instead of just the consequences. Personalize weight loss programs to support, not stigmatize. Learn what makes fat unhealthy in some people and not in others.
For real progress to come, they agreed, society must stop blaming people for a medical condition that is beyond their control. And people must stop blaming themselves.
"There's a lot of misperception among patients that they can somehow 'behavior' their way out of this – if they just had enough willpower and they just decided they were finally going to change their ways, they could do it," said Dr. Sarah Kim, an endocrinologist at the University of California, San Francisco.
For the vast majority, trying to will or work themselves to thinness is just a prescription for misery, she said.
"There's so much suffering associated with weight that is just so unnecessary."
Like many people who struggle with weight, Hiebel has a family tree that includes others with extra pounds. Her mother was heavy, as were other female relatives.
In childhood, Hiebel simply loved food. It gave her pleasure. A buzz.
In fourth grade, her mother brought up her weight with the pediatrician. He prescribed amphetamines.
"I was a fat kid who always wanted to be skinny," Hiebel said. "My whole life. I wanted to be healthy. Thinner."
She blamed herself. For not pushing away from the table sooner. For enjoying what she ate. For the thoughts about food that popped into her head every 30 seconds all day long. For not being able to throw away the plate of cake until she had devoured every bite.
Even though she was trained as a nurse, Hiebel, was petrified of getting medical care. "I spent 50 years largely avoiding doctors because they're going to weigh me," she said.
People who experience and internalize weight stigma are more likely to avoid health care and report lower quality of medical care, research shows.
Many fear the waiting room won't have chairs strong enough to support their weight. They won't fit on the examining table. The doctor will mock or criticize them for being overweight without offering realistic advice for how to lose their extra pounds.
"We treat them as if we obviously don't care because obesity must be their fault," said Dr. Fatima Cody Stanford, an obesity medicine specialist at Massachusetts General Hospital. "We just tell them to eat less and exercise more, and when that fails, as it does 95% of the time, we don't do anything about it."
And people with obesity continue to punish themselves. Stanford tells a story about a patient whose weight kept climbing even after being prescribed medications that are usually effective.
The woman confessed she wasn't taking the prescription because she hadn't tried hard enough to lose weight on her own and didn't deserve it. "I only do 15,000 steps a day," the woman told Stanford. "I feel like I should be doing 20,000."
Stanford ended up persuading her to take the medication. She explained that if someone had a disability weakening their legs, it wouldn't be a failure for them to use a wheelchair.
Hiebel had excellent insurance coverage, but she remembers overhearing her internist arguing with the insurance company to get her weight loss surgery covered. She was required to try Weight Watchers for at least six months and a second weight loss program for another six months, although data shows the vast majority of people can't lose substantial weight and keep it off.
It felt as if the whole insurance industry was telling her she was guilty for being fat.
Shame and embarrassment led Hiebel to avoid seeking help when she started regaining weight after the surgery. "People did all this work on you. You spent all this time and energy and you're failing yet again," she said.
But she didn't want to let all her progress fall apart. She eventually went back to her surgeon.
He told her to make an appointment with Dr. Katherine Saunders at Weill Cornell – and to wait as long as was necessary to see her.
When Hiebel eventually found herself in Saunders' office, she heard for the first time in her life the words: "This is not your fault."
"In my head, I'm going, 'Of course it's my fault. I'm weak. I've got no willpower,'" Hiebel said.
Saunders told her weight loss would take hard work. Her body was conspiring against her to keep on the pounds. The free snacks in her office break room would be a constant temptation.
She offered Hiebel some new tools, including medication to address metabolic issues and her mental state.
With other weight loss doctors, Hiebel felt embarrassed to return for another appointment until she had lost 10 pounds. That often meant never going back. But Saunders told Hiebel to call immediately if she started to struggle.
"She was inoculating me against that from the beginning," Hiebel said. "'This isn't your fault. I can help. And if you get into trouble, don't do what you would normally do and actually call me.'"
The medication gave Hiebel some stomach problems. Saunders warned her that might happen and told her to tough it out for a few weeks. They would adjust the dosage or prescription if it got too bad.
Hiebel's pounds started melting off. She felt great.
Then, for two days, Hiebel found herself repeatedly standing in front of her pantry. "Just looking," she said. "I'd grab a cracker or shut the door. But you keep going back."
Without noticing, she had missed two daily doses of Contrave, a prescription weight loss pill that also helps with mood disorders. Hiebel resumed taking the pills, and her pantry-gazing ended. "I went back to my normal habits almost overnight. Literally."
That's when she realized the power of the medications – and of the drive she carried within her.
"I always felt controlled by food," she said. "Everything was about not eating."
But the metabolic changes from the surgery and the boost from the medications finally changed that dynamic. Raw cookie dough, once her "fifth major food group," lost its grip on her mind. "I kind of don't really want it," she said.
She can throw away a piece of cake after just a few bites, even leaving behind the icing. "Now I'm that person," Hiebel said, "not because I somehow have the willpower, but because I don't really want it.
"I feel liberated around food."
Easy to gain, hard to lose
Weight gain may be as simple as consuming more calories than you burn, but weight loss isn't as simple as burning more calories than you eat.
The human body evolved over tens of thousands of years to hold on to excess calories through fat.
"The default is to promote eating. It's very simple, very logical. If it were not this way, you would die after you're born," said Tamas Horvath, a neuroscientist at the Yale School of Medicine. "When you live out in the wild, you need to be driven to find food, otherwise you're going to miss out on life."
Severe calorie restriction is dangerous, said Horvath, who, with his colleague Joseph Schlessinger, has been studying the brain wiring that drives hunger.
In a study of mice whose calories were severely restricted, one-third lost weight and lived longer, as the experiment set out to prove, Horvath said. But nothing happened to another third. The remainder died young.
"When you engage in such behavior, you are basically playing Russian roulette," he said.
Restricting calories seems to slow metabolism, meaning the body needs less fuel. "You have to keep restricting more and more to keep losing weight," said Dr. David Ludwig, an endocrinologist and researcher at Boston Children's Hospital. "This is a battle between mind and metabolism that most people don't win."
Genetics play a role, too. Some people seem destined from birth to be thin, like everyone else in their family.
Only about a quarter of the population, those with a genetic gift for thinness, seem to escape extra pounds in today's food climate. Even these lucky few can develop the same metabolic problems seen with obesity, becoming "thin outside, fat inside," according to Jose Ordovas, a professor at the Friedman School of Nutrition Science and Policy at Tufts University.
And everybody doesn't gain the same amount of weight from overeating.
A 1990 study showed that a group of identical twin men fed an additional 1,000 calories a day for three months led some to gain roughly 10 pounds and others to gain 30. The twin pairs varied substantially from each other in how much weight they gained and where, but each twin responded nearly the same as his brother.
Overeating can distort the nerves in the brain that receive signals from hormones, said Aronne, at Weill Cornell.
"As you get more damage there, fewer hormonal signals are able to get through and tell your brain how much you've eaten and how much fat is stored," he said. "As a result, your body keeps expanding your fat mass."
Exercise doesn't lead to weight loss either. "You can't easily exercise off obesity," said Marion Nestle, an emerita professor of nutrition and food science at New York University.
Still, experts agree that regular exercise is crucial to health at any size. And it may help prevent weight gain and regain.
"The Biggest Loser" TV show ran on NBC for 17 seasons, following participants as they lost weight through diet and exercise. In 2016, Kevin Hall, a National Institutes of Health researcher, examined what had happened to 14 of the 16 contestants from the 2009 season.
All but one regained some or all of their lost weight, Hall found. But the contestants who remained the most physically active kept off the most weight, he reported in a 2017 analysis of the results.
"The benefits of exercise when it comes to weight don't seem to show up so much while people are actively losing weight," he said, "but in keeping weight off over the long term."
Adequate sleep also is essential for maintaining a healthy body weight and can help with weight loss, studies show.
To accomplish everything she wanted to do in a day, Hiebel often limited her sleep to five to six hours a night. Her solution to the resulting exhaustion was to snack. She remembers frequent coffee and cookie breaks, "as self-defeating as that is."
Many people make the same decision to sleep less – and end up eating more.
In a study published earlier this year, people who had extra weight but not obesity were encouraged to sleep 1.2 hours more a night for two weeks. They ended up consuming 270 calories less a day than the volunteers who slept their typical 6½ hours or less a night.
"It's about sufficient sleep making you feel less hungry, making you want to consume fewer calories," said Dr. Esra Tasali, who led the study and directs the UChicago Sleep Center. "Basically not eating the extra chocolate bar."
Even though she knows how to work the system from her years in the insurance industry, Hiebel is struggling again to get her medication covered by insurance.
She may have to switch to two low-cost generics, provided at the wrong dose. "I'm going to have to cut a pill into fourths with a razor blade," she said. "It's ridiculous."
But Heibel will do what she must to keep off the extra weight.
She feels healthier without those pounds. She used to dread the hills she faced on hikes with her husband. After losing weight, she barely notices them.
"We're not talking about Everest," she said. "I'm not running marathons, but I can do this stuff and I don't huff and puff."
Before she started weight loss medications, she was heading into pre-diabetes. She had borderline high cholesterol and was managing hypertension. Now, her LDL and HDL hover around 70; 60 to 100 is considered optimal.
Just knowing it was possible to break food's grip on her life, that there was hope, was transformative.
Hiebel wants to talk publicly about her story, about the shame she endured for decades, because she wants others to know it's not their fault and help is out there.
The incident with the Contrave made her realize she'll probably need to take a constellation of medications forever. And they still give her a rumbly tummy sometimes.
It's a small price to pay, she said, "to do something that for 50 years I wasn't able to do."
"I'm happy as a clam, and I'm not looking back."
Contact Karen Weintraub at firstname.lastname@example.org.
Health and patient safety coverage at USA TODAY is made possible in part by a grant from the Masimo Foundation for Ethics, Innovation and Competition in Healthcare. The Masimo Foundation does not provide editorial input.