And today I lost faith in obesity treatment

 

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.

Coming Out as Fat

Today I listened to an episode of "This American Life" that was shared by a colleague. http://www.thisamericanlife.org/radio-archives/episode/589/tell-me-im-fat

It's moving. It's long, and you should listen to all of it.

But as an obesity researcher, it brings to light so many other important issues. As we try to change the "epidemic" of obesity, what are we really changing?

If we take individuals--especially children--and manage to help them lose significant amounts of weight, have we simply left them healthier, or have we created entirely new people? Living in the world as a fat person and as a thin person are two very different experiences.

From the episode: "It’s just such an unbalanced reward system. It took so much more kindness, hard work, and ingenuity to be a person in the world when I was fat."

And what happens when people lose weight and experience the world as a thin person, then regain it? I've done it, so I'll tell you. It magnifies what it takes to feel on even standing with your friends and colleagues. There has to be something--kindness, hard work, and ingenuity--that "makes up for" the obesity. You know what it feels like to fit in the chairs, to eat without guilt, to be able to buy clothes and partake in the simple act of getting dressed; and with that knowledge, you are overwhelmed with the intensity of the shame of what you should be.

Imagine that, if you haven't experienced it. Imagine living every moment of every day knowing that what you are is supposed to be transient, something you should always be trying to change. Now imagine being able to just come out and say "this is who I am" and I don't want to change it. This is not the same as saying "I want to be fat". This is like saying "I want to be the same person I am now", whatever happens to the body or whatever I decide to do with my life.

I want the children in our world to be healthy. But that healthiness encompasses mind and body, as well as their place in this world. I want children--everyone--to realize that people with obesity are just people. Obesity interventions shouldn't simply focus on doing no harm, but also need to prepare individuals to live "on the other side" (and, most likely, return). That reality may be as difficult to tolerate as the shame they had to begin with.

Dr. Sharma's "How to Lose 50 Pounds and Keep Them Off"

Dr. Sharma is one of my all-time favorite people. He does such a wonderful job explaining obesity.

His demonstration of obesity is spot-on: "I see just another chronic disease."




More from Dr. Sharma: http://www.drsharma.ca/

The Label of Obesity

This ad from seca showed up in my inbox today, and was brought to my attention by one of my colleagues, leading me to rescue it from the junk folder.

We wonder why medical professionals are a major source of stigma for individuals with obesity, but that's not at all surprising, given this is what they are exposed to. The ad suggests that tagging people--quite literally in the picture--will motivate and improve patient satisfaction.

Understanding body composition CAN be useful for people who are aiming to reduce fat mass, providing information that is more nuanced and useful than weight alone. But we do NOT put a tag on people, as if they were a 50/50 cotton/poly blend. I can see how this advertising campaign may be successful with some clinicians. But the last thing patients with obesity need is another label, and being "labeled" with body composition is no better than being labeled by BMI, unless it is information that patient has deemed useful for them.This is the core of patient-centered medicine.


There are so many ways to approach this, and this is not necessary. (And no, also putting a tag on the shoulder of trim person under "sports medicine" applications does not make this better.)