I'm sure people can use diet and exercise to keep the weight off. At the end of the day, it's all "calories in calories out".
If your body is telling you 24/7 that you're hungry, it's very hard to ignore that drive - it's literally one of our most basic hardwired instincts. Even more so if you have a particularly stressful life or get poor sleep, which also feeds into the hormone issues.
So yes, it is always "calories in - calories out"... but unless you're willing to lock people in a lab and have a third-party control the diet, you also have to consider the mental and biological factors that drive how many calories people's bodies are seeking out.
Diet and exercise do work for some people, and is always the best option when it works. But we also know from decades of failed diets that they do not work for many people - lifestyle modification has a terrible success rate.
Trying to ignore being hungry it is a poor strategy. The solution is to to make peace with the sensation of hunger.
I do think most obesity should be treated as a mental health issue rather than a physical health issue.
The issue isn't that the person is obese - that's the symptom. The issue is that they're overheating. "What's driving me to overeat?" is the question they need to be asking themselves, and that answer will be the first piece of the puzzle.
Most obese people became obese in childhood. In obese people, especially those from childhood that were forced to always clean their plate, signaling pathways for satiation tend to stop working, so consuming a "normal" amount of food becomes difficult. Furthermore, mechanisms for hunger in obesity function very similarly to mechanisms for cocaine or alcohol addiction.
Drugs like Ozempic finally allow their biological signals for "you've had enough food" to actually work, so obese people can lose weight because they feel satiated like normal people do.
FWIW I have lost weight both ways - 80lbs through sheer will, and 25lbs through Mounjaro. I vastly prefer the second. The former is the hardest thing I have ever done (or will likely ever do) in my life. It was harder than getting into a top college, harder than anything relating to my career, harder than literally any other endeavor I've taken. It is definitely unreasonable to expect the average person to expend so much extreme mental effort when alternatives exist to become healthy.
I was SO hungry, it was indeed one of my dominant thoughts other than wanting to kill myself (or distract myself with hot hand warmers in between puking). It virtually never truly went away, other than when I was distracted by even worse senations.
What I then struggle to understand is why my obese and well-off father with a LOT of free time can't make the decision to stop eating fast food, can't consistently stick with not buying presumably very immediately gratifying and pleasurable fast food that often makes him feel sick later. Why I could actually have made radical changes to my diet years before I ever had that level of extreme suffering, or consistently rejected taking any opioids or weed even when my tolerances were probably more reset 1 or 2 weeks in and they could've provided substantial short-term escape from that hell.
I ask in this manner not to try to "brag", as if there's some achievement in meaningless and random suffering, but rather to ask about and understand how you might interpet it. I feel like I've experienced severe and truly engulfing hunger + pain. Coming out of that, I don't understand why some people can't escape the "addiction" of overeating unhealthy food, let alone too much of it, and others can escape the throes of drug dependency.
What could be so alien about someone like me compared against my own father, as opposed to his being in an active refusal to try?
Ultimately, it all seems to me like the issue isn't one of avoiding pain so much as refusing not to experience constant cheap pleasure, and yet given the same opportunities of similar constant cheap pleasures I've mostly avoided them in seeing the longer term pain lying in wait behind their facade. I feel as though the only definitive observation I can make there is that most obese people can't seem to see their condition similarly. They can get hyped up selling themselved and those around them a meme "diet plan" while its easy in their mind, but once it comes time to do the hard work of rejecting harmful habits all the cheap fun imagining the future disappears and they quit, simply ignoring all the downsides by trying to embrace even more pleasure.
Well, addiction is a difficult thing. Most people with a serious addiction will never be able to overcome it. A small number of people will have the willpower to get through the withdrawal and engulfing suffering related to it.
> it all seems to me like the issue isn't one of avoiding pain so much as refusing not to experience constant cheap pleasure
People that are addicted to food, cocaine, or alcohol don't want to be addicted to it. They hate their constant urges. When I was at my worst I didn't want to eat the food I was eating. But fighting that urge requires a monumental amount of willpower people often simply don't have. It's not a "willpower deficiency" just as we wouldn't call a normal person willpower-deficient if they couldn't kick a cocaine addiction.
> once it comes time to do the hard work of rejecting harmful habits all the cheap fun imagining the future disappears and they quit, simply ignoring all the downsides by trying to embrace even more pleasure.
Yeah, they give up - which to me is completely unsurprising given how hard losing weight and kicking that addiction is for some people. See, given how addicted you are to food, a diet plan could range from merely "hard work" to "so ridiculously hard that your psychology can't handle it".
This is why I think medicines like Ozempic are critical. They enable you to lose weight without needing to exercise Herculean feats of willpower if you are very addicted to food (especially if you have been since childhood.)
Exercising the willpower to not eat when you're hungry is only a Herculean effort if you've stopped exercising it regularly for a long time.
At any given moment, we might have multiple conflicting desires (e.g. "I want to eat this pizza," and "I want to lose weight"), and it takes a lot of mental practice to be able notice when this is happening, and take a moment to identify which of your wants are base urges and which are real, higher-order desires, then align your actions with the higher-order ones. Meditation helps, and for those that really struggle with exercising executive function, therapy can help as well. But it takes a lot of practice and sustained effort. Habits change quite slowly and most of the work of losing weight is building the right mental frameworks so that you can start changing habits. Trying to brute force weight loss is like trying to swim the English channel with no training - you're going to fail and might hurt or even traumatize yourself in the process, which will make it even harder if you try again later.
Medication does work and it has its place, but because it comes with side effects and does not resolve the underlying mental issues that are driving the addictive behavior, I really do feel it should be a last resort for the most serious cases of addiction, not the first line of attack. It's possible you and I may agree on this point, but many don't, and refusing to acknowledge that obesity is primarily a psychological issue is doing more harm than good.
Addiction mechanics play a role here. It's not just willpower, it's willpower minus addiction. The second variable is absolutely massive, it snowballs over time, and it's why addiction treatments often have more interventions than just willpower.
As such, it's a thousand times more difficult for an obese person to "simply not eat" than it is for a normal person to "simply not eat." To the normal person, not addicted to food, it might seem simple, like the obese person simply lacks willpower, but in the obese person's shoes the normal person would likely end up the same way.
Hence, the obesity epidemic - it sneaks up on you.