Sunday, August 19, 2012

Is Weight-Loss Advice Unethical?

Over the next little while, I will be taking a few days off and so I will be reposting some of my favourite past posts. The following article was first posted on Aug 31, 2009:

This week’s issue of Newsweek quotes me as saying, “A lot of our weight-loss recommendations are unethical because we shouldn’t be saying lose weight when there is no chance people will keep it off“.

This quote appears in the context of a lengthy article by Daniel Heimpel that examines whether or not the obesity epidemic is being oversold.

While I personally do not think that the obesity epidemic is being oversold, I do stand by my statement that most of the weight-loss advice given to patients with overweight or obesity is unethical.

In medical school, I was tought the principle of “primum non nocere” or “first, do no harm.” This principle begs us to always consider the possible outcomes (including the unintended ones) of any actions that we take with our patients, including of course the advise we give them.

So what are the potential ethical concerns about telling someone to lose weight?

1) The way this advise is presented: it is certainly no secret to the readers of this blog that weight-bias is widespread, not least amongst health professionals. As a result, the weight issue is not always addressed in the most sensitive or professional manner, thereby often resulting in little more than having the patient cancel all future appointments.

2) The advise that is given is of little help: as most health care professionals lack even the most basic understanding of the sociocultural, psychological and biological determinants of energy regulation, they generally boil this down to “less energy in and more energy out” or “eat less, move more”. Most physicians will in fact primarily recommend exercise, actually the least effective method to lose or control weight. Patients, who recognize the futility of this advice (most often because they’ve been there and done that), are likely to have less confidence in their physicians’ recommendations, even in areas in which the physician may well be competent and knowledgeable. This can clearly have a negative impact on the patient-doctor relationship.

3) Rates of recidivism or weight regain are virtually 100%: In General, interventions, where the rate of recidivism is that high (especially in severe obesity, with the exception of bariatric surgery), should be recommended with caution. Weight loss takes time, resources, motivation, and dedication, and despite the best intentions and early success, the vast majority of patients will regain any weight they lose and, in some cases, end up heavier than before. This setback generally comes at a cost, if only a diminished motivation to ever address this problem again. This state of affairs is by no means made any easier by the fact that most patients (and physcians?) will ultimately put the full blame of failure on themselves (on the patient) – another blow to an already low self esteem.

4) Unhealthy weight loss strategies: Patients, who do take the advise to lose weight seriously, are generally left to do so of their own device. This opens the field to all manner of commercial and non-commercial weight loss products and services, little of which has any proven long-term efficacy (the only weight you lose in the long term is the weight of your wallet). Without proper guidance and surveillance by licensed and trained health professionals (like for any chronic disease), chances are high that patients will make the wrong choices, thereby setting themselves up for failure and frustration with a high likelihood of ultimately only making things worse than better.

5) Lack of hard evidence of benefit: Believers in “evidence-based” medicine should listen carefully: there is to date no evidence whatsoever that intentional weight loss (short of bariatric surgery) will lead to a reduction in “hard” outcomes (heart attack, stroke, death). Any evidence on health benefits is limited to improvements in surrogate measures and risk factors or to “soft” outcomes like quality of life. While these are certainly important, we need to realize that any promise of a longer life with weight loss is premature and not based on any hard outcome trials. As a result, we need to be very clear with ourselves and our patients that currently, the best we can expect is indeed an improvement in comorbidities and perhaps in quality of life – there is, however, as yet no guarantee that weight loss will actually increase the likelihood of playing with your grandchildren.

I will spare my readers the fascinating discussion on the increased rates of depression and even suicidality that has been observed in some weight-loss studies.

It should be clear from the above, that the often well-meant but lightly given advice to simply “lose a few pounds”, when presented in the wrong manner, the wrong setting,  and/or without professional guidance or support, has the potential to do more harm than good and should therefore not be nonchalantly offered to all patients with overweight or obesity without a careful consideration and discussion of pros and cons as well as likelihood of success.

Remember, as blogged before – successful weight management starts with limiting further weight gain – a much more achievable and sustainable goal than losing weight and keeping it off.

AMS
Edmonton, Alberta

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14 Responses to “Is Weight-Loss Advice Unethical?”

  1. Anonymous says:

    The LEAST helpful advice is

    “We shouldn’t be saying loose weight when there is no chance people will keep it off.”

    OH NO!! If there’s NO CHANCE I might as well give up NOW!!
    However, defying all rationality, I will persist in trying to loose weight and keep it off…!!

    The National Weight Control Registry (nwcr.ws) tracks people who actually have lost weight and kept it off.

    Do you think this group does good scientific study?

    There must be other SCIENTIFIC studies of weight REGAIN or MAINTENANCE after weight loss? ( Not commercial testamonials..)

    As a layperson, I don’t understand the chemistry and metabolism of weight control, so I rely on blogs like yours with medical-scientific cred to translate scientific studies. Now that weight regain has been identified as a significant phenomenon, I hope it gets the analytical study it needs.

    Right now weight regain “just happens”. The “cure” was provided, and if the patient then regains weight, it’s his or her own fault. In fact, the medical team is exasperated because the patient “undoes” all the good work the medical team did. Even people who try to be sensitive and avoid weight bias when dealing with overweight patients loose a bit of their sensitivity when the patient regains weight. Might as well just plan

    Weight REGAIN needs to be studied and analyzed, not just expected and tolerated.

  2. Christina says:

    Another thought provoking and insightful article. Just wondering about point five. You have blogged before on health benefits of losing 5-10% of weight and you have also mentioned the 2009 Lancet study of 900 000 individuals which found that while a BMI of 30-35 is linked to reduced life expectancy between 2-4 years, a BMI of 40—45 (about 100 lbs overweight) life expectancy is reduced by 8—10 years (which is comparable with the effects of lifelong smoking). Could you please clarify about weight impacting life expectancy?

  3. wellroundedtype2 says:

    I can’t thank you enough for this list. It is such an excellent summation of the ethics of promoting weight loss by physicians.
    What I find with the physician and endocrinologist I currently work with is that, short of bariatric surgery, they don’t encourage me to lose weight, rather, maintain the weight I’m at and be sure to get as much activity as I can. I’m the one asking about options — not for weight loss per se — but for alieviation of some of the “side effects” of being the size I am while I age. On balance, while surgery is the best shot at losing weight, I’m not convinced for me it’s my best shot at quality of life.

    In terms of quality of life, I think it is worth looking at things that can catch weight gain earlier in the process and move people to weight maintenance earlier in the process. I think the weight bias and lack of efficacious treatment hurt the doctor-patient relationship, and make it harder for a good practitioner to say — “what is going on that is causing your weight to increase right now? Has something in your life changed? Is there anything that you think could help in preventing gaining weight? Is there anything I can offer you in terms of support that would make it easier to stay where you are right now?”
    I gained about 50 pounds in my early 20s, when I didn’t have a regular “medical home” — and the providers I encountered often made things worse — until I was ultimately diagnosed with type 2 diabetes at age 25. If I’d had a provider who could have said to me — “What’s going on that is causing your weight to go up so rapidly? Do you need any referrals?” I might have been able to make changes earlier — but it’s also possible that I would have rejected that intervention anyhow. Because for me, the weight I was at “naturally” was already high, I don’t think the “excess weight” was seen as just 50 pounds, but more like 100 pounds or more. (I also think your perspective on “excess weight above ideal weight” is brilliant.)
    I think getting people who are past pediatrics into a medical home is another important idea. This is a time when young adults are exposed to many different health risks, and providers who connect well with this age group — whether in the college setting or outside of it — could make a huge difference, even with things like seatbelt use and tobacco cessation. Because this age group is generally considered to be healthy, the care that is given is mostly acute care, but it’s such an important age for preconception counseling, as well as mental health.
    Okay, so, that was longer than I intended it to be. I was so glad to see you quoted in the Newsweek article.

  4. living400lbs says:

    Anonymous,

    For an overview of diet studies, I would suggest you check out Medicare’s Search for Effective Obesity Treatments: Diets Are Not the Answer (PDF). UCLA researchers lead by Traci Mann reviewed 31 studies on diets and recommended that the US Medicare program not cover diet programs because they are not effective enough to be worth Medicare coverage.

    The weight control registry is very self-selected, since it’s about people who are successful at losing 30lbs and keeping it off for one year. While this is an achievement, most dieters do not complete their regain within one year. To quote from the Mann study, “The more time that elapses between the end of a diet
    and the follow-up, the more weight is regained.”

  5. Anonymous says:

    I agree with wellroundedtype2 that it would be good to catch weight gain earlier and help people to maintain weight earlier.

    Now that we know that any weight put on will stay on unless you have bariatric surgery, avoiding weight gain is crucial.

    Looking back, one of the mistakes I made regarding my weight was thinking that if I gained a couple of pounds over Christmas or had an enormous birthday binge or ate my way out of a bad mood, I could always go on a diet and loose the weight later.
    I used to think my friends who carefully watched everything they ate and went into panic mode if they gained 5 lbs were picky and paranoid and far too concerned with their weight.
    Well, they have been proven right. I’m now trying to be just as picky as they are about diet and exercise. They’re continuing to work hard to maintain their healthy weights, and I’m working just as hard to keep myself “only” 70 lbs overweight and to manage my associated medical problems.

  6. Anon to living400lbs says:

    Thanks for reference to Mann’s study. I’m working on getting the pdf (my computer won’t read it) I did find the abstract and several interviews with Mann.

    Two comments:

    1. The study seems to use the word “diet” to specifically refer to weight loss programs that are temporary and calorie restricted. You would “go on a diet” to loose weight, then “go off the diet” when you reached a goal.

    I use the word “diet” in a different sense, to mean a planned, permanent eating program designed to meet specific nutritional needs. A diet isn’t always for weight loss- it could be for weight gain, or to keep an active athlete in top form, or to deal with kidney disease or food allergies, or to keep a healthy normal-weight person healthy.

    Mann herself says “Eating in moderation is a good idea for everybody”. I’d call that a “diet”, because it’s planned and controlled, but apparently it’s not considered a “diet” for this study.

    The study “Diets aren’t the answer” means “temporary calorie-restricted diets that you go on then go off and resume your old way of eating – aren’t the answer.”

    That’s good to know! It’s especially good to know if sellers of these programs are trying to get government money even though their diets aren’t effective.

    Still, if controlling weight is a goal, just because the on-again-off-again-low-cal diets are no good, doesn’t mean you don’t have to have a food plan that meets your nutritional needs, even if you don’t want to call it a “diet”, and even if it’s only part of the total weight control program.

    Comment 2:
    1/3 to 2/3 or more of people on these “diets” regained weight or gained even more after a few years.

    If people resumed the old habits which had caused them to gain weight in the first place, it makes sense that they would resume gaining weight and so eventually they would catch up with or surpass their pre-diet weight.

    The people who should be studied are the minority who didn’t regain weight. Like the people on the National Weight registry, they lost weight and kept it off.

    The fact that these people are exceptions is what makes them interesting.

    When smallpox was epidemic, someone noticed that milkmaids didn’t get smallpox. They were the exceptions. The scientist investigated and found the milkmaids had had cowpox which had made them immune to smallpox. This led to smallpox vaccines.

    I don’t mean there’s an obesity vaccine to be discovered ( wouldn’t that be nice!), I
    just want to know more about what the exceptional people are doing that leads to their success.

    The nwcr is self selected for successful weight loss. I’ll bet there are many people out there who are successful at loosing weight who don’t trumpet their success, and who are not picked up by any researchers.

  7. wellroundedtype2 says:

    I suspect that for those people who are able to lose weight and maintain the weight loss, there is something other than “willpower” going on — I suspect that they may have gained above their “set point” and are able to return to it when perhaps some others are not, or just have a “weight thermostat” that is set higher. If someone maintains a certain weight for a number of years, and then gains weight above that point, and loses the weight they gained but regains only some of it, they end up higher than where they were initially, but lower than their highest weight. I don’t think this is the rule, more likely it’s people who, for one reason or another, found their weight higher than where they felt comfortable and took some action to change it, and had some degree of success. These people may never regain to their highest weight but end up in the middle.
    Is it worth studying these people? Maybe, but I doubt that what one will find will be applicable to people who find it much harder to maintain weight loss, not because they’ve returned to old habits, but because their bodies and brains found the new habits unsustainable, and did everything in their power to get them to burn fewer calories and eat more calories. There are many mechanisms that the body has in place to send the message to stop eating, because the drive to eat is so strong it needs these systems to prevent constant eating in the presence of plentiful food, but to drive more eating when food is scarce. These “stopping mechanisms” are easily overridden, easier in some people than others.
    I’m most interested in what people who have a predisposition to gain weight can do to have the best health they can. This might involve things that help prevent weight gain, or things that make it easier to be healthy at a high weight (but one that is for them, normal and sustainable) — such as physical activity geared for larger bodies.

  8. Anon to wellrounded says:

    Agreed that being healthy as possible at any weight is a worthy goal.
    And keeping a steady weight is an accomplishment that requires planning a program and analyzing results and modifying the program as needed, until you find what works for you. In that respect it’s just like a weight loss program.

    Yoni Freedoff ( a colleague of Dr Sharma) in his Weighty Matters blog mentions Willett, Harvard prof, who analyzed many diets, and said the best way to find what works was to experiment on yourself. (Within reasonable limits and with doc’s help, I mean.)

    The point is to continually get feedback so you know what to keep doing and what to change.

    The value in studying success, whether it is in loosing weight and keeping it off or maintaining a satisfactory weight, is that you discover factors which other people have found helpful which you might not have thought of.

    For example, a weight loss camp for teenagers (I think it was Academy of the Sierras or Wellspring) found the kids had no structure around eating. They snacked continually. I thought that was like me, so I added definite times to eat and snack to my routine, tracked how I did, and decided a schedule was a real help to me. If I’m hungry, I don’t panic and snack because I know I’ll be eating soon. If I’m very hungry and realize I missed a meal or snack I know why, and I don’t feel like I’ve just totally lost control. This idea of keeping on schedule might seem totally obvious to someone else, in fact most people would probably find it stupid of me to need to find out I needed a schedule. But hey, I copied someone else’s success, tested it, and found it worked for me. Other people control weight by eating little during the day, then enjoying a big dinner. I’ve experimented with that and found for me it’s disaster.

    Other factors:
    U of Ohio advise to post-bariatric-surgery patients: get enough sleep. I realized that a trigger for me to overeat was not getting enough sleep, then trying to get enough energy to get through the next day by eating way too much especially carbs. I still miss sleep sometimes, but I can recognize my carb cravings and binging as my body trying to deal with exhaustion. My mother used to say “You’re weary, dear, have a cookie”. Not a good idea, and it took me years to realize this was a problem for me.

    Dehydration: I realized that I never feel thirsty, I feel hungry. So now I’m aware that if I’m unable to eat or drink all day (my schedule isn’t always possible) I should drink water first, because I’m probably thirsty even though I don’t feel thirsty, just hungry.

    Eat some protein and some carb at each meal or snack – this seems to work for me. I’ve tried other diets that stress eating lots of fibre to fill you up – that doesn’t work for me, I just end up feeling full and hungry.

    I’ve tried to test and incorporate some of the things done by the people who loose weight and keep it off at the national weight registry – not because these things are magic bullets or cure-alls, but because every little thing may help.
    1. Eat breakfast. 2. Weight regularly. 3. Have a routine diet with limited variety that’s nutritionally adequate but not fancy. 3. Don’t go off routine for weekends or holidays. 4. get regular planned exercise (my downfall – I’m still planning on doing this, some day) 5. Be methodical about weight control even if that’s not your usual way of doing things. etc etc.

    As I’ve tried to control my weight – and for me that means loosing weight because I don’t want to stay obese – I have found researching what has worked for others has shown me factors affecting my weight that I never even thought of. I don’t expect to find a magic bullet. I do want to find as many factors as possible because weight control is so complicated. The more things other people have used successfully that I can test on myself, the better.

  9. Bill Moe says:

    I follow the newsletters of Jack Medina of which I would like to quote:
    “Promises, Promises!
    How to Know if the Claims are for Real
    December 2004
    ——————————————————————————–

    As I travel and speak worldwide I see more and more advertising in magazines and on TV for “products” that promise weight loss, muscle growth, increased endurance capacity and much, much more.
    Endless Claims
    Twelve issues of popular body building and health magazines were surveyed to add up the number of advertisements for food supplements, the number of products being advertised, and the number and type of ingredients in these products. In addition, the claimed benefits were examined.
    Eighty nine brands, 311 different products, and 235 supposedly unique ingredients were counted, the most frequent of which were unidentified amino acids. The most frequently promoted health benefit was muscle growth. Twenty two percent of the products had no ingredients listed in their advertisements. Claimed benefits were everything from stimulating the central nervous system, facilitating recovery from exercise, to acting as a supplemental fuel source.
    The Problem
    When you demand to see good “third party” published research to support claims being made about a “product”, having asked the following questions you will eliminate 95+% of the so-called performance-enhancing or fat-burning products being advertised today.

    Evaluating Validity of Research Claims

    Here are some key points to help you identify good, believable research:

    Justification – is the research based on sound rationale?

    Subjects – animal or humans? Must be adjusted for age, sex, baseline levels of training, nutrition, health.

    Random Assignment – random assignment is better than using volunteers who could bias the study.

    Double-Blind – subjects and administrators are both unaware of which group subjects belong to until after results are in.

    Placebo-Controlled – there is a “control” or test group and a “placebo” or non-test group for comparison to determine significance of the study.
    Control of Outside Factors – experiences should be similar for tested groups, except for the item being tested.

    Appropriate Measurements – reproducible, objective, and valid measurement tools must be used to study the research question.
    Conclusions – must be both statistically significant as well as significant in practical terms.

    Publication of the Research

    In addition to the above characteristics, the following are also important to give further credence to the study:

    Published in Peer-Reviewed Journal – quality research withstands critical review and evaluation by experts in the field. Publication in popular magazines or non-professional journals do not undergo the same review as peer-review. In fact, self-appointed “experts” in sports nutrition and physical fitness pay big bucks to eager publishers for magazine space to promote their particular viewpoint. In some cases, the “expert” owns the magazine.

    Findings Reproduced by Other Researchers – results from one study do not necessarily establish scientific fact. Agreement through research duplication reduces the influence of chance, flaws in experimental design, and investigator bias.

    The manufacturers of the hundreds of so-called performance-enhancing products or “fat-burners” are after your money. They don’t have to tell you what is or isn’t in their product; they don’t care about possible side effects or loss of eligibility. They are not going to spend the money or take the time necessary to have good research done to confirm their claims. So they play on your desire to have something happen fast–regardless of the possible consequences.”

    For me, not having a researcher in the family, following Dr. Sharma’s blog and Jack Medina has given us insight as to a methodology to determine the legitamicy of health products.

  10. Aggie says:

    “I will spare my readers the fascinating discussion on the increased rates of depression and even suicidality that has been observed in some weight-loss studies.”

    I am quite interested in this subject. The only time in my adult life that I lost a significan amount of weight (55 pounds), I also became extremely depressed, had suicidal thoughts, and my behavior was impulsive. I would say hurtful things to the people I loved and had quite a few family problems due to that. I thought I was losing my mind.

    Now I am back to my previous weight and worried about the consequences for my health, since I am close to being a type 2 diabetic. It just seems I am damned if I do and damned if I don’t.

  11. FatChickinLycra says:

    Not surprising, Aggie. The 1944-45 Ansel Keys Minnesota Starvation Experiment resulted in tremendous mental distress and depression.
    http://en.wikipedia.org/wiki/Minnesota_Starvation_Experiment

    People with mental illness often struggle because many of the most effective medications for certain conditions cause weight gain and have adverse effects on cholesterol and glucose levels.

    Health is a multi-dimensional thing. We all have to make our own assessments and choose the path that’s best for us in situations like yours.

  12. DeeLeigh says:

    From the Wikipedia entry on Ancel Key’s semi-starvation experiment:

    Among the conclusions from the study was the confirmation that prolonged semi-starvation produces significant increases in depression, hysteria and hypochondriasis as measured using the Minnesota Multiphasic Personality Inventory. Indeed, most of the subjects experienced periods of severe emotional distress and depression.[1]:161 There were extreme reactions to the psychological effects during the experiment including self-mutilation (one subject amputated three fingers of his hand with an axe, though the subject was unsure if he had done so intentionally or accidentally).[5] Participants exhibited a preoccupation with food, both during the starvation period and the rehabilitation phase. Sexual interest was drastically reduced, and the volunteers showed signs of social withdrawal and isolation.[1]:123-124 The participants reported a decline in concentration, comprehension and judgment capabilities, although the standardized tests administered showed no actual signs of diminished capacity. There were marked declines in physiological processes indicative of decreases in each subject’s basal metabolic rate (the energy required by the body in a state of rest), reflected in reduced body temperature, respiration and heart rate. Some of the subjects exhibited edema (swelling) in their extremities, presumably due to the massive quantities of water the participants consumed attempting to fill their stomachs during the starvation period.

    What people often don’t seem to understand is that calorie restriction to maintain weight loss creates a persistent state of semi-starvation. $20 (sorry, I’m kind of broke) says that’s why you’re seeing depression and suicide increase in people who are maintaining large weight losses.

  13. ruthdemitroff says:

    You could take every point you’ve made and substitute telling a patient they aren’t young anymore and ideally they should work to turn back the aging process to twenty-five or at least stop their body at its current state because of all the health risks of being old. The costs of an obese population and the costs of an aging population probably favour an obese person dying at 65 from the same degenerative diseases that a super fit person will die from at 120.

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