Sunday, September 25, 2016

And today I lost faith in obesity treatment

 You are ill 2

Recently, the New England Journal of Medicine posted a case vignette, allowing respondents to choose whether a woman with obesity should be offered lifestyle modification or lifestyle modification along with pharmacological therapy. Currently, 81% of respondents have said they would offer only lifestyle modification. This post isn't about whether that is right or wrong (it's neither), it's about the responses in the comments.

Here is a sampling of the recommendations that would be made by physicians:

  • No pharmacotherapy because of my search of the "lay literature"
  • Unsweetened seltzer instead of soda
  • One glass of nonfat milk and cereal for breakfast, leafy greens for lunch, and 1 hour of walking per day
  • I personally loose [sic] weight on a low carb high fat diet
  • Becoming active is all in your brains and it is her choice
  • The secret is to not eat. A person can eat enough eating once a day.
  • The President Taft diet
  • A change in soul that requires a change from top to bottom of every minute of every day
  • Yoga, because the core of those programs is self-discipline
  • Cut out all hidden sugars, stop eating breads, rice, cakes, potatoes, crackers, and all processed foods
  • Eat functional foods
  • Paleo
A significant number of the responses included some variation of the personal anecdote--Well, I lost weight on...

This is not a random message board. These are what physicians say they would tell their patients to do. They point to fad diets, anecdotal and non-scientific evidence, personal opinions, and simple personal choice.

And we actually wonder why people report experiencing weight bias from their health care providers, and why people struggle to lose weight even when attempting to work with their providers.

Obesity is such a complex issue that even most physicians aren't adequately equipped to address the problem. I believe that doctors do want to give the best advice for their patients, but the bias, some overt and some implicit, against people with obesity that echoes through these responses is disheartening.

The menu of options for weight loss treatment is long, and little evidence clearly supports one option over others for most people. The only "right" answer, if there is one, is to present all options to a patient and let them decide. Different approaches work for different people, as indicated perfectly in the physician responses to the question.

A few of the respondents did suggest this patient-centered choice, as well as a couple who noted that almost any option would fail without public health support. A few others note that after years of obesity, a much more productive approach would be to focus on improving health, with or without weight loss.

A physician's job is to help individuals determine ways to improve their health. Telling a patient--literally--to simply not eat is not going to achieve that. In a perfect world all physicians would have complete information about obesity. Obesity is complex, and that will not happen, so it becomes particularly critical to recognize what you don't know. Unlike so many other health conditions, where the role of specialty care is easy to accept, obesity is wrapped up in social beliefs and personal biases.

Doctors and other health care providers are not immune to these, but they also have a unique ability to have a most powerful effect on individuals, simply by saying: "Obesity is so hard and I don't have a perfect answer. Let's figure this out together."

Maybe I won't lose faith after all.


  1. You nailed it Asheley. No perfect answer exists. A skilled physician can work with a patient to find an individual best answer. The best obesity medicine physicians know it's an iterative process. You described it beautifully. Thank you.

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