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Several years ago, I was meeting a young woman in my clinic for the first time. She was healthy but had been obese most of her adult life, even though she had tried many methods of losing weight. We spoke for a few minutes about diet and exercise, and she agreed to see the nutritionist.
A few months later, she came back to check her progress. She had lost weight, about five pounds, but was concerned because her heart “felt like it was racing.” After I questioned her extensively, she told me she was using a weight loss drug she bought from a friend. She wasn’t sure what was in it, but I knew similar drugs had been found to contain amphetamines. She agreed to throw the drug away. She regained the weight.
Since then, I have worried that telling patients to lose weight is harming them. These conversations fail to acknowledge how rare weight-loss success is: Fewer than 1 in 100 obese people will achieve a normal weight. We also continue to equate normal weight with good health in spite of mounting evidence that this is not true. In fact, in some studies, patients who are classified as overweight live longer than those who are a normal weight.
For those who will benefit from slimming down, my five minutes of counseling are no match for the toxic culture of weight loss, a culture so desperate that people spend billions of dollars on supplements that may contain speed. In fact, there is no evidence that even an hour or two of this kind of advice helps patients lose any weight, according to Dr. David Grossman, vice chair of the United States Preventive Services Task Force.
When Weight Loss Is Ominous
When I tell patients that they should lose weight, without providing them the resources to do so or being honest about how difficult it is, I leave them vulnerable to messages that they are lazy if they can’t, and that even dangerous methods of weight loss are worth the risk. More disturbingly, we may ignore unintentional weight loss in our patients — and they may do the same — even though this can be an ominous sign.
Marjorie Williams, a reporter for The Washington Post, wrote about the weight loss she not only ignored but celebrated: “I was too happy enjoying this unexpected gift to question it even briefly: the American woman’s yearning for thinness is so deeply a part of me that it never crossed my mind that a weight loss could herald something other than good fortune.” By the time she went to her doctor, she had end-stage liver cancer.
I don’t deny that obesity is a problem. One in five premature deaths is linked to obesity. Most guidelines, including those issued by the United States Preventive Services Task Force, continue to encourage doctors to screen for obesity. These recommendations, however, are based on data that rigorous, long-term weight loss programs — not the brief counseling we provide in the office — can lead to sustained weight loss. We need to get serious and stop pretending that telling patients to lose weight without giving them the tools to do so is an acceptable intervention.
Many doctors agree we need to change how we approach obesity, but are divided about how. Some argue that we should embrace high-intensity programs and new prescription weight-loss medications. Others say we should stop counseling altogether.
For patients who need more help losing weight, Dr. Robert Kushner, professor of medicine at Northwestern’s Feinberg School of Medicine, believes physicians should consider weight-loss medications approved in the last five years. Studies suggest that diet and exercise alone led to a loss of about 2 percent of a person’s weight, he argues, while those who took newer medications lost about 10 percent. For patients who suffer from complications of being overweight, such as diabetes, high blood pressure or sleep apnea, he notes that the difference in weight loss could mean a significant improvement in overall health.
The 'Path Of Least Resistance'
There are persistent concerns about the safety of these medications, however, and other doctors believe their use is short-sighted. “I would call it the path of least resistance. I’m not sure it’s the answer to this problem,” Dr. Gordon Schiff, director of quality and safety for the Harvard Medical School Primary Care Center, told me in an interview.
Schiff argues that “promoting and prescribing drugs to treat obesity does a disservice to our patients, society, and ourselves.” Little data exist on the new drugs, he said, in a field where past weight-loss drugs have been deemed either unsafe or ineffective. Health-care providers, he believes, should focus on lifestyle changes and advocate for changing our patients' environments to prevent them from gaining weight in the first place.
But Kushner says that safety concerns, while understandable, are no excuse to “sit on the sidelines.” Our understanding of obesity medications “is like the beginnings of diabetes and high blood pressure medication 40 years ago,” which many doctors were once reluctant to use because of safety concerns.
Maybe both doctors and patients need to reduce their expectations. Dr. Pieter Cohen, general internist at Cambridge Health Alliance, counsels patients that intense lifestyle changes can lead to modest, but important, results. “I am often talking to patients about making aggressive lifestyle changes today so that when we meet in two to four years, they might be 1 to 5 pounds lighter," he said. "But if you did nothing you might be 10 to 20 pounds heavier.”
Traditional Counseling: 'Overly Simplistic And Unproductive'
Meanwhile, some patient advocates have begun to declare that our brief counseling is not only ineffective, it falsely gives the impression that weight loss is a simple matter of will power. Patients share stories of being dismissed by physicians who assume they do not take care of themselves. Kushner bemoaned the traditional “eat less, move more” style of counseling as overly simplistic and unproductive. “I think it causes a sense of futility,” he said. “It causes a sense of frustration. It causes shame. It leads to hopelessness in the patient, because they’re asking for help and the person they're asking for help says, ‘Do the same thing you’ve been doing for 10 years, just try harder.’ That’s not an answer. After a while, the patient stops bringing it up at all.”
Some doctors have wondered if we should simply stop counseling patients. Dr. Roger Ladouceur, the associate scientific editor of the Canadian Family Physician, wrote that the causes of obesity, deeply rooted in our genetics and environment, are “very difficult to change." Do doctors “believe that those who are overweight don’t realize it?" he asks. "They have been called fat since their early childhood.”
Yet Kushner argues that, given the many ill effects obesity can have on our health, it is time for providers to double down instead of giving up. This is “probably how alcoholism or depression” were talked about many years ago, he said, with physicians identifying the problem but offering patients nothing but brief counseling. “Now we don’t let anyone go through the system without offering them help. And those used to be thought of as personal failings too.”
Even with all this uncertainty, I think a few things are clear. First, we need to stop pretending that what we are doing is working. Our brief counseling sends the wrong message that weight loss is simple and easy, even though we know it’s not. We have to be frank with patients and tell them the truth: If they are willing to make weight loss a central goal of their lives, they can lose about 5 percent of their body mass. They can even keep it off if they change their lifestyle dramatically, and forever. We need to focus more on exercise, which will help people be healthier, even if they remain overweight.
For now, when patients ask me about weight loss, I spend more time warning them about the dangers of unregulated supplements and other extreme methods. I explore the feelings of worthlessness and shame that so many attach to their bodies. And when they do manage to slim down, I am much quicker to worry about how.
Elisabeth Poorman is a graduate of Cambridge Health Alliance and a primary care physician in Everett, Mass. She tweets at @DrPoorman.