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When To Recommend Weight Loss For Obesity



Obesity medicine, which I define as the medical care of someone living with obesity, should approach patients holistically with the aim of improving their overall health and well-being. Advice to lose weight may or may not be part of obesity management – much can be gained for someone living with obesity by promoting their health behaviours, getting them to feel better about themselves, improving their mental health, and helping them better managing their health issues.  Much of this can be achieved with no or very little weight loss.

Thus, we must consider the question of when weight loss would specifically need to be part of the treatment objectives.

In my own practice, I approach this problem by considering the following three questions:

  1. Is this a problem unrelated to abnormal or excess body weight?
  2. Is this a problem aggravated by abnormal or excess body weight?
  3. Is this a problem caused by abnormal or excess body weight?

From what I hear from my patients, the most common mistakes in medical practice fall into the first group – trying to address unrelated issues with weight loss recommendations. There are endless stories of patients going to see their health provider with problems clearly unrelated to their body fat (e.g. a broken arm, a sore throat, the flu, depression, migraines, etc.), who simply get told to lose weight. Indeed, there is evidence to suggest that patients with obesity are less likely to undergo diagnostic testing, most likely based on the assumption that their problems are simply related to their excess weight. This is not only where grave medical errors can be made (late or misdiagnosis), but also where the advice to lose weight is clearly wrong. If the presenting problem has nothing to do with excess weight, then no amount of weight loss will fix it.

The second category deals with issues that are not causally related to abnormal or excess body fat but where the underlying problem either causes more symptoms or is more difficult to treat because of the patient’s size or fat distribution. There are countless medical problems that fall into this category. For e.g.  a heart or respiratory problem entirely unrelated to excess weight (e.g. a valvular defect or asthma) can become worse, cause more symptoms, or be much more difficult to treat simply because of the patient’s size. This group also includes issues like neck or joint pain from a trauma (e.g. a motor vehicle or skiing accident), reflux disease (e.g. from a hiatal hernia), urinary incontinence (from multiple child births), etc., etc., etc. – the list is long. Here, although obesity has nothing to do with the underlying problem, weight loss may alleviate the symptoms or at least make them more manageable (they are however unlikely to be fully resolved). These patients present with what may be described as a relative or “secondary” indication for weight loss. Of course, if there are viable treatments options for the primary problem, then this is where the emphasis should be. Weight loss can best be considered as “second-line” treatment. It would be completely unethical to withhold effective treatment for the underlying problem just because of the patient’s size (as in, “no treatment for you until you lose X lbs!”)

Finally, we have the third category of health issues that are directly causally linked to the excess weight – in most cases, the problem did not exist prior to weight gain and losing weight is often likely to completely resolve the problem (unless the patient has already sustained irreversible organ damage). This group of health issues not only includes the vast majority of cases of type 2 diabetes, hypertension, obstructive sleep apnea, fatty liver disease, infertility, etc. but also all of the functional limitations that people may experience simply because of their excess body fat. This is the only category of patients who would be deemed to have a “primary” indication for weight loss. Losing the weight literally solves their problem. Indeed, trying to manage the problem without weight loss is nothing less than “palliative” care. This is not to say that weight loss will always guarantee success even if the underlying problem is directly related to excess weight. For e.g. although there is ample evidence that excess weight is a prime risk factor for gall bladder disease, (rapid) weight loss may actually promote formation of gall stones. Similarly, although intertrigo (skin fold infections) can occur as a direct consequence of excess weight (e.g. chaffing), losing weight may actually make the problem worse by deepening the skin folds. Thus, even in this category, one needs to carefully consider risk-benefit ratios.

Of course, any recommendation to lose weight must take into account the complex nature of obesity in the first place and the fact that long-term weight-loss maintenance will require an approach (behavioural, medical, or even surgical) that takes into account the chronic relapsing nature of this disorder. Simply telling people with obesity to “eat less and move more” is about as medically sound and effective, as simply telling people with depression to “cheer up”.

Both, to avoid grave medical errors and to not insult their patients, I strongly recommend that medical practitioners first approach all their patients with obesity based on the assumption (that their presenting health issues are unrelated to their excess weight) before considering possibilities two (unrelated but aggravated) and three (causal). Advise to lose weight has no role in situation 1, can be considered in situation 2, and is clearly the best course of action for situation 3.

@DrSharma
Edmonton, AB

 

4 Comments

  1. Thank you Dr. Sharma. I work as a health coach and personal trainer in a clinical setting with an internist here in Los Angeles. I am referred any patient with a lifestyle behavior issue, smoking, drinking, stress and insomnia. Of course many patients are overweight. I rarely suggest weight loss as a start and I build rapport as I uncover what symptoms match what behavior. It takes about 12 half hour visits before a plan is in place and a patients can begin to understand how they gained weight and why. Approaching weight loss this way, we untangle the raw emotions of becoming overweight, and relieve the stress that dieting can cause.

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  2. The only time it’s appropriate to recommend weight loss surgery is if the doctor thinks the patient would be better off dead than managing a health condition as a fat person, because that is the risk they are taking. There are treatments for all of the so-called “category three” issues that don’t involve weight loss. These are the treatments that thin people with these health issues receive. The problem here is that currently, medical science sees fat lives as inherently more risk-able than thin lives and so, while thin people would not be asked to risk their lives, or horrific irreversible lifelong side effects to control Type 2 Diabetes, doctors are very comfortable asking fat patients to do exactly that.

    There are three possible outcomes of weight loss surgery. Group one is happy with the results (often even if the results include difficult side effects or additional emergency surgery.) Group 2 live with horrific lifelong side effects and would do anything to take the surgery back. Often these people can be found in support groups with names like “Weight Loss Surgery Ruined My Life.” Group three are people who die and can no longer tell their stories.

    No doctor can tell someone which group they are going to be in, until that person is in that group for life (or death.) Even if a doctor thinks it’s appropriate to recommend this surgery, they MUST inform their patients of the possibility of ending up in groups 2 and 3, and the other treatments (the ones thin people receive) that have less risk, if they want to be practicing ethical medicine with informed consent.

    And, again, in order to justify the recommendation for weight loss surgery, they must believe that a patient is better off dead than managing a health condition as a fat person.

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  3. Lots of fantastic points here, including the harm that’s done by attributing problems to weight that are unrelated, as well as not withholding treatment until someone loses X number of pounds. I do understand that weight loss makes some surgeries easier, but well, take my mother’s situation: She already lost 40 lbs, is not too far from her ideal weight and needs back surgery. Her back surgeon never weighs her, doesn’t acknowledge the weight she lost, and says he won’t consider surgery until she has gastric bypass surgery, which her PCP says is contra-indicated (ulcers, gastroparesis and a lifetime need for NSAIDs due to aggressive osteoarthritis). Besides, she doesn’t have much more weight to lose and the surgeon who was to evaluate her for bariatric surgery suggested removal of loose skin on her belly instead (he’s the one who would have been involved with future surgery as they’re going in through mom’s front and back for her back surgery!).

    Her back surgeon tells her to have bariatric surgery, tells her to swim… (She’s got 4 broken screws and her back is unstable now).

    Just tell her: “I don’t feel confident that I am the best surgeon for your case.”

    Instead, he tells her he won’t do surgery until she has gastric bypass. And guess what?!?! She already had a breast reduction surgery at his suggestion, and saw the doctor who would have done the gastric bypass and that doctor removed loose skin instead. So, she’s had two surgeries in preparation for a surgery that this back surgeon is never going to do… He’s just going to keep blaming her for being overweight. She sent a note to his office saying that she saw that he hasn’t updated her weight in her chart, that she HAS lost weight, and asking why he won’t proceed with surgery. He sent her a generic diet plan print-out through the online system and that’s it.

    He’s sending her to Johns Hopkins, where I pray she’ll get more compassionate and appropriate care. I’m spitting mad at this doctor of hers. I’m overweight, too, and I’ve had a gynecologist tell me, “Nobody’s surprised to see the fat woman’s obituary in the newspaper” (while he was doing an exam and I felt pretty darned vulnerable anyhow).

    When doctors disregard what I have to say, I have started telling myself that they see me as the FAT woman with complex medical issues that they don’t want to deal with (somehow, having a fibromyalgia diagnosis puts a “KICK ME” sign on my back and the adult-onset allergist-verified food allergies confirm that I’m just a big, fat hypochondriac). It’s their problem, not mine. I’ve wanted to drop out of the medical system, but I’d probably not live long. Some of the advice I get from doctors might kill me even sooner, though. It’s a toss-up sometimes.

    I apologize for my anger and frustration. It’s not directed at you. I pray your colleagues will listen to what you’ve said in this article.

    Your comment about “Eat Less, Move More” being like telling someone who is depressed to “cheer up” was SPOT ON! It’s not just about handing a patient a print-out with a diet plan, but sadly, I recognize that that’s as much training and education doctors get. I love my PCP, and he’s so compassionate… and I felt he wanted to really help. He’s not equipped. Why doesn’t my insurance help me talk to someone who can address the habits and behaviors that keep me from having success? It’s not a lack of knowledge. I lost 175lbs in the past through the DASH diet. I was telling doctors that I was exhausted and I hurt. I asked one doctor for a sleep study, and was told I was “just depressed” and given a script for anti-depressants (a rheumatologist had written her a letter telling her I had fibromyalgia but neither she nor the rheumatologist told ME my diagnosis).

    About 5 years later, after being on a slew/rotation of medications to help me sleep, I got sent for a sleep study and was diagnosed with sleep apnea. I also have widespread osteoarthritis. I’m 38 years old.

    If patients ever rant, it’s because they’ve been through… “it all.” (ahem)

    I’m grateful there are caring doctors out there. That’s who I kept on my team. I’m pushing ahead with weight loss efforts, but I know I don’t have access to specialists who can address the behavioral/habit issues, so I’m going to figure it out somehow. It’s a wonder that, if obesity plays such a huge role in chronic illness, that insurance companies can ignore the need to honestly address patient need for support.

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  4. Thanks for sharing this! After college and following a heartbreak 3 years ago, I have used food as a way of comforting myself. Because of so, I have put on considerably a lot of weight.

    Since then, I have never been happy with myself and the way I look. I went into mild depression and there was practically no one I could turn to.

    I wanted to change all that and with that, starting by loving myself and my body all over again. I am looking for effective online fitness programs suitable for beginners that I could commit to and hopefully yield gradual results to stay motivated.

    I’ve gone through this particular review https://greatbigminds.com/best-diet-to-lose-belly-fat/ and it looks viable to me, though I am still not certain if it’s as easy as it sounds. Has anyone heard of that program or has any experience with it?

    If not, would highly appreciate if you can recommend one that I could possible look into.

    Thank you for the help in advance.

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