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Should Doctors Stop Telling Patients to Lose Weight?



This Month’s edition of Canadian Family Physician, the official journal of the College of Family Physicians of Canada, features a debate on whether or not family doctors should stop telling their patients to lose weight.

On the Pro side, we have Jana Havrankova, an endocrinologist at Clinique familiale Saint-Lambert in Quebec, notes that keeping weight off is anything but simple.

The few patients who manage to lose weight and keep it off achieve something truly remarkable. From a public health standpoint, however, the treatment of obesity is a failure.

Thus, rather than trying to treat obesity, Havrankova places her bets on prevention:

“Efforts at prevention involve some degree of telling people what to do, and some people will criticize this. Screening and monitoring excess weight from early childhood, ensuring that physical activity is part of the curriculum right up to university, creating neighbourhoods that encourage people to get out and walk, and teaching people how to prepare healthy meals are just a few suggestions.”

In the Contra corner we have Dominique Garrel, a specialist in endocrinology and metabolism and Full Professor in the Department of Nutrition at Université de Montréal, Quebec.

Not only does Garrel argue that obesity must be treated, but also that the treatment of obesity can be simple and effective. However, treatment needs to focus on health and not on weight loss.

“Treat the patient, not his weight. Telling an obese patient to lose weight is about as effective as telling an asthmatic patient to breathe better! Care consists of assessing the risks of excess weight to a patient’s health. The Edmonton Obesity Staging System recently proposed by Kuk et al [sic] is an interesting tool designed for this point of view. This system includes recommendations for each level of intervention, ranging from simply recommending that the patient maintains his weight, to recommending bariatric surgery.”

He also points out the importance of recognising and treating comorbidities as these may often represent roadblocks to weight management, to set reasonable (read ‘modest’) objectives for weight loss, and inform the patient of the tools at his disposal for losing weight (as well as warn them against unhealthy weight loss efforts).

In an accompanying editorial, Roger Ladouceur, Associate Scientific Editor of CFP, notes the following:

“Why, then, do we tell our patients to lose weight? Why do we repeat, “You should lose weight”? What’s with that? Somewhat sadistic, don’t you think? Do we do this as a way of shifting the guilt and transferring the responsibility of the therapeutic failure?”

In fact, Ladouceur concludes with the rather profound statement that:

“All things considered, shouldn’t we put a stop to this preoccupation with our patients’ weight and simply encourage them to develop healthy lifestyle habits, to adopt a balanced diet, to practise on a regular basis any form of exercise that they enjoy, even if it is simply walking? Instead of repeating “You should lose weight,” shouldn’t we help them to become more comfortable with themselves?”

Although this statement may not at all sound ‘profound’ to regular readers of these pages, such an ‘insight’ printed in the ‘house journal’ of the CFPC, which goes out to every family doctor in Canada, represents a major step forward in our thinking about obesity – if anything, it certainly moves right into the mainstream of what the Canadian Obesity Network’s experts and Family Practice Group has been saying all along (and is about to promote with a nationwide program due to be released in the next few days).

Not only am I happy to see promotion of the Edmonton Obesity Staging System, but am also particularly pleased to see that both sides (and the editorial) are seeing health as being more than just numbers on the scale.

Neither suggests we ignore obesity or that it does not confer health risks – but they do suggest that it is time to radically rethink the traditional “lose weight and you’ll be fine” approach based on the simplistic notion of “eat-less move-more”.

Incidentally, this debate and editorial accompanies another article in this edition of CFP with the title: “The Downside of Weight Loss” – more on this paper in tomorrow’s post.

AMS
Grand Prairie, Alberta

Hat tip to the Canadian Obesity Network’s Primary Practice Working Group member Dr. Shahebina Walji, Calgary, for alerting me to these articles.

5 Comments

  1. As most Canadians are slowly gaining a bit of weight over time, I would like to see reducing the amount gained or to stop gaining weight as the first goals / plan discussed with a patient and only if that is attained then losing weight could be reviewed. As you have said many times Dr. Sharma, if a person is able to avoid gaining weight each year that is certainly effective obesity management.

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  2. Hooray for Roger Ladouceur! Sadistic is both a courageous and precise word. And YES, the net effect is to shift guilt and dodge responsibility for prescribing a bogus therapy. Is there any other therapy that doctors prescribe with the knowledge that more than 90% of the time it will fail long-term? Worse, that its failure will likely create more problems (such as depression, gall stones, impaired immune function and a higher body fat percentage) than the presenting condition? Wow.

    I hope this editorial signals a sea change, and living in the states, I hope the waves are rushing south.

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  3. Or, how about telling ALL your patients to work towards a healthy lifestyle, not just the heavy ones? Thin is not the same thing as healthy.

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  4. I like both points of view. Dr. Havrankova is focussing population approach, while Dr. Garrel is focussing individual approach. Both approaches are different but can reinforce each other. And still remains the task to take care of the obese adult individual, even when the treatment seems to look like “unsuccesfull” … The emphasis on “evaluation” (by EOSS) seems to me important, just like the definition of “realistisc targets” different from weight loss, followed by lifelong “coaching” (which we appreciate as normal in the treatment of hypertension, cardiovascular disease, …) Concerning EOSS – 1-2 patients, hasn’t changing lifestyle habits the “side effect” of moderate weight loss ??

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  5. . . . or at least if they are going to tell their patients to “lose weight,” they might then provide some insight, information and/or guidance into just how this might be accomplished.

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