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I sympathize with the frustration that Dr. Elisabeth Poorman expressed in her recent post: Why I've Stopped Telling My Patients To Lose Weight. And I agree with her that for primary care physicians, there is a problem: Ineffective weight loss counseling may bring few benefits, or even backfire.
But as a specialist at Massachusetts General Hospital who has spent more than a decade treating patients with obesity, I disagree that silence about weight is an acceptable solution.
Just when I thought the medical profession was gradually accepting the fact that obesity is a disease — a highly regulated, complex disease with a strong biological basis — Dr. Poorman's post reminds me that we still have a long way to go.
Because obesity is not a simple disease, weight loss is difficult for both the patient and for the physician, and weight maintenance is even harder. A poll released this week finds that among Americans with obesity, one in five has tried 20 or more times to lose weight. We, as medical professionals, need to treat obesity seriously — and treat our patients who have obesity with respect.
Patients look to their doctors for medical and nutritional advice, and the mere acknowledgement of the body mass index is helpful for the patient’s perception of their weight and to spur more weight loss attempts.
Although a lack of time is often cited by doctors as a barrier to effectively counseling patients on weight, there is no clear evidence to suggest more time beyond the usual “five minutes” of counseling is effective. The issue is how a patient is counseled, not how long.
The trouble is that physicians commonly resort to the simple message of “eat less and move more,” and tell patients that they "should" lose weight (as if patients with obesity don’t already know they should lose weight), which clearly is not helpful. This message is no more effective than telling a person with depression to “cheer up.”
Also, weight bias is common among medical professionals and leads to worse care in those patients who have obesity. One study found that doctors spend 29 percent less time with patients with obesity compared to average-weight patients, and are more likely to consider the encounter a waste of time.
Too often, a doctor believes that people with obesity are lazy, eat too much, and lack the willpower to maintain a healthy diet, and blames the patient for the lack of weight loss. One of my patients, who had gained weight after being placed on steroids for her rheumatological disease, was told by her specialist at a local academic hospital, “Just wire your mouth shut” when she asked for help to lose weight.
Rather than labeling weight regain or the lack of weight loss as a failure of the patient with obesity, doctors should consider this a poor response to the treatment. When chemotherapy fails or when someone requires insulin for their diabetes, do doctors blame the patient? There is a double standard for obesity and it highlights doctors' lack of understanding of obesity and the available treatment options. As a result, patients with obesity are more likely to avoid medical care altogether.
The true disservice is having a physician who doesn’t hear the long-term struggle, the numerous weight-loss attempts, and doesn't investigate reasons for the weight gain.
Changes in sleep, stress, menopause, smoking cessation and numerous medications have been associated with weight gain. Some of these modifiable lifestyle factors should be identified as potentially damaging, and treated.
Setting expectations is also crucial for both the patient and physician. We should appreciate non-weight outcomes such as changes in waist circumference or a reduction in cholesterol. End points — three to six months, for example — can be established to pursue different treatment options in those who do not respond. Doctors don’t treat all cancers the same, nor do they treat all diabetes the same. Obesity is no different.
We have to tell our patients that obesity is a “health issue,” as Dr. Poorman nicely points out, but also recognize that if a patient is not losing weight on diet “A” or exercise plan “B,” or by stopping a potential weight-gain-promoting medication, then we need to consider additional treatment options.
Many currently available weight-loss medications and weight-loss surgeries are safe and effective. However, the public and medical establishment still tend to believe that the medications are no different from the amphetamine-based “diet pills” that were used decades ago, and that weight loss surgery is a barbaric operation requiring patients to drink liquid shakes for the rest of their lives. These are common misconceptions.
We also need to stop framing obesity as a lifestyle choice and recognize the biological underpinnings of this disease. In the last two decades, since the discovery of leptin — a hormone released by our fat cells that acts much like a gas gauge on a car dashboard — our understanding of how the body controls our appetite has dramatically expanded.
We know lifestyle is not the only factor to blame for the growing obesity problem. In fact, we know that obesity is a highly heritable disease, which presents in many different forms. And where we hold our weight can have a significant effect on our risk of developing chronic diseases like Type 2 diabetes and high cholesterol.
Those dreary statistics that suggest that most people fail to lose weight and almost nobody manages to keep the weight off can be misleading. The real truth is that we don’t know how much weight a particular person may lose with a particular diet, change in sleep habits, or exercise routine.
We do know that weight loss surgery is the most effective weight loss treatment, resulting in 20-35 percent body weight loss after one year. We do need to be realistic about weight loss outcomes, but also optimistic that there are many options to help our patients lose weight.
At the same time, we know there is great individual variation in treatment response. For example, clinical trials on weight loss medications have shown only modest weight loss of 3-9 percent after one year, yet I have had patients lose 45, 60, 120 pounds with a medication during that time.
We know that just 5-10 percent body weight loss can bring a significant improvement in our risk for cardiovascular disease and cancer, and it can reduce the number of medications needed for obesity-related medical conditions. But perhaps most importantly, those who lose 5-10 percent in one year are most likely able to keep it off after several years. In addition, early weight loss is important, and predicts long-term weight loss for particular interventions, including lifestyle modification, anti-obesity medications and weight-loss surgery.
In the end, I agree with Dr. Poorman that there is a need to change how doctors approach patients with obesity. But I would argue that we should be willing to treat obesity as the disease that it is. And that means we start by talking about it.
Dr. W. Scott Butsch is an obesity medicine physician who practices at the Massachusetts General Hospital Weight Center.
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