A Weight-Skeptical Approach to the Care of Patients with Obesity

[mgriffiths]

...and here I am...up way later than I should be.  I'm going to bed shortly.

 

But, I will say that the above is probably the most well thought out and persuasive writing I've read online.  For that I will say well done, and continue to think about this and how it applies beyond even just "high BMI" patients.

We're not as far off from each other as I think some of the posts may appear, which is probably why it's as persuasive as it is.  But we are likely coming at this from differing starting points and therefore different points of emphasis.  But, overall I want to thank you for sharing the lecture video.  It's much better and significantly more thought provoking than anything provided by my employer, which is also why I actually did want to come back and watch the full lecture once I had a chance. 

[True Anomaly]

I’ve watched the whole thing, and I definitely have some thoughts- especially as someone who’s been morbidly obese before

I agree that BMI is a bad term, and the utility of it has been watered down to where it’s now too emotionally charged for many people to be effective when discussing this very issue with patients.  I think a more correct term is “increased adiposity”, since it’s the presence of more body fat that does correlate with increased negative health outcomes.  And while he is correct that people with increased adiposity aren’t guaranteed to have worse incidence of T2DM or cardiac disease or even hypertension, the risk is still greater than if they had a lower percentage of body fat.  And the “healthy at any size” discussion ignores the numerous other ways that increased body fat hinders someone’s ability to simply live and function.  Simply put, it is harder to do daily activities while carrying excess body fat.

He is also correct that there are many people- and I’ve certainly experienced this too- who feel hopeless and shamed for being overweight or obese or have increased fat or whatever you wish to call it.  You do indeed feel more afraid to seek healthcare because you’ve been convinced that any discussion about your health starts with your weight, and you feel ashamed that you can’t control it. So his approach to being more open about health discussions with patients like this does make it easier to develop trust and hopefully compliance about how to handle it.

HOWEVER….where I vehemently disagree is this idea that there is a “set point” where you can’t seem to lower your weight no matter what you do.  And during the Q&A afterwards, someone did ask about whether set point was truly “set” or if it can be adaptable, and he really didn’t have a good answer.  Sure, leptin and ghrelin are powerful satiety/hunger hormones and definitely impact someone’s ability to either gain or lose weight….but telling people that there is a  “set point” that they have little control over is actually a mentally damaging thing IMHO.  

I totally bristle at anyone who suggests that just because there is a propensity for people to gain the weight back after losing it means that they can’t do it long term.  It just means they haven’t found the long-term strategy that works best FOR THEM- which is a much harder thing to do, but is entirely achievable.

What I sincerely fear is people who truly want to lose weight who are going to be caught up in the idea that “healthy at any size’ means that they can’t find a way to lose weight, so they give up and accept that “this is my reality” when they probably don’t want it at all. 

The science between weight gain and weight loss is not up for debate in my mind.  What IS up for debate is how we teach nutrition to people.  

[rev ronin]

6 hours ago, True Anomaly said:

I totally bristle at anyone who suggests that just because there is a propensity for people to gain the weight back after losing it means that they can’t do it long term.  It just means they haven’t found the long-term strategy that works best FOR THEM- which is a much harder thing to do, but is entirely achievable.

What I sincerely fear is people who truly want to lose weight who are going to be caught up in the idea that “healthy at any size’ means that they can’t find a way to lose weight, so they give up and accept that “this is my reality” when they probably don’t want it at all. 

The science between weight gain and weight loss is not up for debate in my mind.  What IS up for debate is how we teach nutrition to people.  

People CAN lose weight and maintain that loss long term. The vast majority won't. Failing to maintain weight loss increases metabolic stress, and THAT can apparently prompt T2DM. Potentially harmful interventions need good logic behind them. I'm not going to want my family med doc to do a CABG, I want a cardiothoracic surgeon.  That's a bit hyperbolic but maybe we should take "weight loss counseling" out of the hands of PCPs, since the way they've been doing it hasn't worked.

As far as people who truly want to lose weight go... I really don't care what they say they want. Mind you, I deal with people who pathologically try and starve themselves by limiting intake to 400kcal/day, or induce vomiting multiple times daily, or who try and clock up 40,000 steps/day on their fitbits. Just because someone WANTS something doesn't mean 1) it's achievable, or 2) they're going to go about it in a healthy and sustainable manner.

Should there be a better way who want to lose weight to go about it? Probably, but the prevalence of fad diets suggest that a LOT of people who are choosing terrible approaches would need to be redirected into the new pathway. With the cost of GLP-1s and the like, I'm not sure it's a cost effective thing--Medscape ran an article earlier this week or last criticizing the cost of new Diabetes drugs. I didn't have to open the article to know they're talking about SGLT-2s and GLP-1s. Why should insurance pay for something that is likely not going to work, will be very expensive, and may make things worse?

Science is always adapting and expanding, finding new information and new applications. However, much like Newtonian physics is useful but incomplete, there are more things going on. How long was it we discovered that weight loss caused decreased metabolism?

 

I'm guessing you weren't able to lose weight and go back to how you'd been eating before. Since you successfully maintained your weight loss, I'll bet money that you changed your entire lifestyle--eating, exercising, possibly sleeping and TV watching--to make that stick.  GOOD FOR YOU. I never want to let my pessimism about what the average patient can statistically achieve cut into the well-deserved praise for those who are able to make it work.  On an individual level, you rocked it and deserve praise.

[True Anomaly]

The cartoon below - to me- highlights a big part of the problem that you’ve also noticed Rev: we as medical practitioners are not equipped overall to help people with nutrition counseling.  Set aside that there is a whole profession dedicated to this (RDs), but I do feel that the primary medical practitioners who see patients should have a better overall understanding of how it actually works.  That’s WAY easier said than done of course, and would require a fundamental shift in how we view nutrition

My n=1 experience for how I was able to do it successfully is just one tiny data point.  It’s not a “one size fits all” approach (no pun intended).  But with the overall knowledge out there, and especially with what I’ve learned over the past year, I know there are better ways to teaching people how this works- and not just other medical practitioners, but our patients in general.  I also don’t know what that looks like, but I’m at the point where I’m ready to change my entire career around to figure it out

[rev ronin]

Some more food for thought. FWIW, I know one of the people quoted professionally.

https://www.nytimes.com/2022/10/18/magazine/anorexia-obesity-eating-disorder.html

 

[CAAdmission]

Here's a related KevinMD piece:

https://www.kevinmd.com/2023/03/lifestyle-change-the-forgotten-solution-in-health-care.html

In part:

For example, the American Academy of Pediatrics issued new obesity treatment guidelines that included medications and surgery. 60 Minutes recently aired a segment with physicians claiming that obesity was mainly genetic and best understood as a “brain disease,” dismissing diet and exercise as outdated and arguing for medication as essential. These represent a semi-abandonment of lifestyle change as treatment. We are losing the obesity epidemic, but instead of bolstering the values underpinning diet, exercise, and other good habits, we lean on impressive new drugs.

 

[Mayamom]

Ozempic for everyone!!