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.