Two patients have high blood pressure. One is thin, one is fat.
The thin person goes to the doctor and receives recommendations for interventions that, evidence shows, are likely to lower blood pressure. When that person goes back for a check-up, the doctor will test their blood pressure to determine if the interventions are working.
The fat person goes to the doctor, and research tells them that there is a greater than 50% chance that the doctor will view them as awkward, unattractive, ugly, and noncompliant, and a nearly 30% chance that the nurse will be “repulsed” by them. (All of the evidence is linked at the bottom of this post)
The doctor recommends weight loss to “cure” the high blood pressure, but does not tell the person that the vast majority of the time people gain all of their weight back within 5 years, or that some methods of weight loss are likely to make the high blood pressure worse. The doctor also doesn’t explain that weight loss is not guaranteed to lower blood pressure even if they are in the tiny percentage of people who successfully maintain weight loss. Rather, they tell the patient that everyone who tries hard enough can lose weight permanently. When the patient goes back for a check up, the doctor puts them on the scale to test their progress.
There are a few issues to explore here with respect to the doctor’s behavior with the fat patient:
The first is the concept of evidence-based medicine. Even if it’s the doctor’s sincerely held personal belief that weight loss will cure high blood pressure, based on the evidence that we have there is no reason to believe that this patient can lose weight long term. In fact, since the evidence we have shows that the majority of patients who attempt weight loss end up regaining more than they lost, if the doctor thinks that being fat is the problem, then recommending weight loss is irresponsible and the worst possible advice.
Often doctors try to explain this away by citing the evidence of correlation between fat and various diseases (“but being fat is so bad that’s you should try to lose weight no matter what the odds!”) It does not matter what issues fat is correlated with, because we don’t know how to make people thin in the long term. Saying that we do is a lie, whether it’s intentional or not. If your doctor tells you that weight loss works, ask her or him to produce a study where a majority of participants were able to maintain a weight loss of the amount that she/he is recommending for you, for 5 years or more. They will not be able to do so. Prescribing weight loss has no efficacy basis in evidence.
The second is an issue of diagnostic criteria. When we use weight as a stand-in for health, we are putting a middle man where we don’t need one. Doctors can test a patient’s blood pressure, give evidence-based interventions to lower it, and then test the blood pressure again to see if the interventions are creating the desired result. It doesn’t make sense to prescribe a body size intervention for a health problem.
Prescribing weight loss for high blood pressure is like prescribing weight loss to cure cancer. (the difference being that weight is simply a body size and cancer is a disease, but it still makes an apt comparison in terms of the way that they are both used in modern medicine). Although we are aware that the treatment for cancer often leads to weight loss, we don’t tell cancer patients that weight loss will cure their cancer. When they come in for check-ups we don’t weight them to measure the efficacy of the treatment. We understand that with cancer interventions weight loss is a side effect. It’s the same with treatment of high blood pressure, diabetes etc. It’s possible that the behavior changes that are recommended for intervention will lead to a change in weight, but that’s merely a side effect, it’s typically temporary, and it’s not a proper diagnostic criteria or efficacy test.
The third issue is of informed consent. Going back to the cancer example, a doctor can recommend a risky procedure to treat cancer. They must tell the patient the odds for success as well as possible side effects and what happens if it fails, and give the patient a prognosis. They cannot tell patients that anyone who tries hard enough can beat cancer, both because it’s not true, and because it irresponsibly sets up a situation where patients feel like it’s their fault when the treatment (that almost never works) doesn’t work for them. They also have to let them know if there are other options. Then the patient makes an informed decision.
A doctor can prescribe weight loss, but informed consent would require that they let the patient know that it only works long term a tiny percentage of the time, that the vast majority of people regain their weight and that the majority gain more weight than they lost, meaning that the majority of the time the “treatment” has the exact opposite of the intended effect. They also have to tell them that, not only does weight loss almost never succeed in lowering body weight long-term, there has never been a single study that proves that losing weight will create the health change they are hoping for.
When we talk about dramatic weight loss the figures drop to be almost non-existent. Doctors also have to let patients know that there is a great deal of evidence that shows that healthy habits lead to healthy bodies regardless of weight. They cannot correctly tell the patient that anyone who tries hard enough can lose weight – that’s not supported by the evidence. They should also inform them that these diseases happen to people of all sizes, but that patients of a lower weight who present with the same symptoms are given a different treatment plan, and explain that plan as an option. Their fat patient may now make a truly informed decision.
Your doctor may not be making these mistakes intentionally. She or he may not know about the studies that I am referencing here. All the same, the evidence is there and we trust doctors to be working from the principles of evidence based medicine, proper diagnostic criteria and informed consent. We should be able to go to the doctor with the expectation that they will not make these mistakes, but that is not the situation in which we find ourselves.
So, as my friend Darryl Roberts is fond of saying, we must be the CEOs of our own health. (Or as I am fond of saying, we must be the boss of our health underpants.) If we are to get good healthcare we must be informed and steadfast in our requirement that doctors treat us based on the evidence. Most versions of the hippocratic oath include a phrase to the effect “I will not be ashamed to say “I know not.” If your doctor is still making these mistakes and is surprised to hear about this research, then now is the time for them to invoke that.
Here is the research, including quotes from each piece:
Research about the failure rate of dieting:
http://www.ncbi.nlm.nih.gov/sites/entrez/17469900 (link goes to study)
“You can initially lose 5 to 10 percent of your weight on any number of diets, but then the weight comes back. We found that the majority of people regained all the weight, plus more. Sustained weight loss was found only in a small minority of participants, while complete weight regain was found in the majority. Diets do not lead to sustained weight loss or health benefits for the majority of people…In addition, the studies do not provide consistent evidence that dieting results in significant health improvements, regardless of weight change. In sum, there is little support for the notion that diets lead to lasting weight loss or health benefits.”
We believe the ultimate goal of diets is to improve people’s long-term health, rather than to reduce their weight. Our review of randomized controlled trials of the effects of dieting on health finds very little evidence of success in achieving this goal. If diets do not lead to long-term weight loss or long-term health benefits, it is difficult to justify encouraging individuals to endure them
“Although long-term follow-up data are meager, the data that do exist suggest almost complete relapse after 3-5 yr. The paucity of data provided by the weight-loss industry has been inadequate or inconclusive. Those who challenge the use of diet and exercise solely for weight control purposes base their position on the absence of weight-loss effectiveness data and on the presence of harmful effects of restrictive dieting. Any intervention strategy for the obese should be one that would promote the development of a healthy lifestyle. The outcome parameters used to evaluate the success of such an intervention should be specific to chronic disease risk and symptomatologies and not limited to medically ambiguous variables like body weight or body composition.”
A panel of experts convened by the National Institutes of Health determined that “In controlled settings, participants who remain in weight loss programs usually lose approximately 10% of their weight. However, one third to two thirds of the weight is regained within one year [after weight loss], and almost all is regained within five years.”
“Consider the Women’s Health Initiative, the largest and longest randomized, controlled dietary intervention clinical trial, designed to test the current recommendations. More than 20,000 women maintained a low-fat diet, reportedly reducing their calorie intake by an average of 360 calories per day and significantly increasing their activity. After almost eight years on this diet, there was almost no change in weight from starting point (a loss of 0.1 kg), and average waist circumference, which is a measure of abdominal fat, had increased (0.3 cm)”
“Findings from this study suggest that dieting, and particularly unhealthful weight control, is either causing weight gain, disordered eating or eating disorders; serving as an early marker for the development of these later problems or is associated with some other unknown variable that is leading to these problems. None of the behaviors being used by adolescents (in 1999) for weight-control purposes predicted weight loss[in 2006]…Of greater concern were the negative outcomes associated with dieting and the use of unhealthful weight-control behaviors, including significant weight gain…Our data suggest that for many adolescents, dieting to control weight is not only ineffective, it may actually promote weight gain”
Studies about healthy habits leading to healthy bodies
“Healthy lifestyle habits are associated with a significant decrease in mortality regardless of baseline body mass index.”
“We’ve studied this from many perspectives in women and in men, and we get the same answer: It’s not the obesity, it’s the fitness.”
“no measure of body weight or body fat was related to the degree of coronary vessel disease. The obesity-heart disease link is just not well supported by the scientific and medical literature…Body weight, and even body fat for that matter, do not tell us nearly as much about our health as lifestyle factors, such as exercise and the foods we eat…total cholesterol levels returned to their original levels–despite absolutely no change in body weight–requiring the researchers to conclude that the fat content of the diet, not weight change, was responsible for the changes in cholesterol levels.”
“With or without consideration of …extremes or gains in body weight…alumni mortality rates were significantly lower among the physically active.”
Research about doctors perception of fat patients
“In a study of over 620 primary care physicians, >50% viewed obese patients as awkward, unattractive, ugly, and noncompliant. One-third of the sample further characterized obese patients as weak-willed, sloppy, and lazy.”
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