What Doctors Should– and Should Not– Say to Obese Patients

Below a remarkably candid and compelling essay by Emma Lewis titled “Why there’s no point in telling me to lose weight. ” It originally appeared in the January 2015 issue of BMJ (formerly the British Medical Journal).  Hat-tip to Helen Haskell, president and founder of Mothers Against Medical Error, who sent me Lewis’ piece.

In her editorial (cross-posted below), Lewis explains why she has “opted out” of the “weight-loss game.”  She confides that she has been “fat” since she was a child. She still remembers the humiliations, which continue to this day– especially when she visits a primary care doctor.

It doesn’t matter whether she is seeing the physician because she has broken an ankle or needs contraception. Inevitably, he or she brings up her Body Mass Index (BMI.) And when a GP admonishes her that she should diet and work out, he rarely asks what she eats now, or how much she exercises.  He doesn’t listen; he lectures.

In fact, Lewis does care about her health: she exercises regularly and has switched to a whole meal vegetarian diet. For years, she has been in good health. But her BMI remains above 30.

What Many Doctors Don’t Know—And What Even the Experts Don’t Understand

What these general practitioners don’t know is what doctors and scientists who specialize in obesity have discovered:  the vast majority of overweight patients cannot shed pounds—and keep them off—even in highly controlled experimental settings where patients diet and exercise under a doctor’s supervision.  As I explain in the post below two years after starting a diet, roughly 95% will have put all of the weight back on.

And even the experts who study the obesity epidemicdon’t understand why.

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Losing Weight—What the Experts Are Reluctant to Tell You – Part 1

Have you ever shed 15 or 25  pounds and, then, over the next year or so, put it all back on? Usually, we blame ourselves.

But, as I reported on HealthBeat in 2008, physicians who treat obese and overweight patients know that only about 5% of us are able to lose weight and keep it off—even in highly controlled experimental settings where patients diet and exercise under a doctors’ supervision. Over two years, 95% of us will put the pounds back on, and in some cases, add more.

A National Institutes of Health (NIH), working group study published in the January 2015 issue of the journal Obesity, confirms that:  “Despite advancements in our understanding of obesity, weight regain after weight loss remains the most substantial problem in obesity treatment – with both the body and the mind conspiring against individual efforts to maintain weight loss.”

                What Randomized Controlled Trials Reveal 

University of Minnesota Psychologist Traci Mann has spent 20 years running an eating lab and, based on her experience, she reports: “Long-term weight loss happens only to the smallest minority of people.”  

Indeed, when she and five other researchers analyzed outcomes for patients in randomized trails where one group dieted, and the other group did not, the studies showed that, after two years, the average patient on a calorie restricted regimen had lost only one kilogram, or about two pounds, while one third to two thirds of dieters had actually regained more weight than they lost. (In many of these trials, the patients not only cut calories, but also exercised.)

What about folks who combine intensive lifestyle changes with drugs designed to help us lose weight? “Studies show that patients on drug therapy lose around 10 percent of their excess weight,” but “the weight loss plateaus after six to eight months,” UCSF’s Medical Center reports. “As patients stop taking the medication, weight gain usually occurs.”

                              Low-Carb vs. Low-Fat Diets 

Does it matter which diets you try?

At one time, most physicians were convinced that fatty foods led to obesity, and a low-fat diet offered the best route to becoming svelte. But in recent years, a growing number of doctors and health advocates have begun to argue that increased consumption of sugar and refined carbohydrates is the most likely explanation for our obesity epidemic. 

Last summer WIRED published an impressive in-depth review of what we do and do not know about whether certain foods will make us fat.

The story notes that that in 2009, “Robert Lustig, a pediatric endocrinologist, rose to national fame after a 2009 lecture in which he called sugar ‘poison’ went viral on YouTube.

 Meanwhile, newer science has undermined the consensus that fat is all that bad for you. A recent meta-analysis published in the Annals of Internal Medicine found no clear evidence that eating saturated fat contributes to cardiovascular disease.”

What about carbs? “In trials, carbohydrate restricted diets almost invariably show significantly better short term weight loss,” WIRED reported, but “over time, the differences converge towards non-significance.”  In other words, the available evidence suggests that over the long term, both low-fat and low-carb diets fail.  

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Over-Eating: Confusing Cause and Effect–Does Overeating CAUSE You to Re-Gain Weight, Or Do You Eat More BECAUSE You Are Overweight?

Today, researchers are digging into what drives weight gain, and some are beginning to suggest that we have been confusing cause and effect.

What if it’s not overeating that causes us to get fat, but the process of getting fatter that causes us to overeat?”

Recently The Journal of the American Medical Association (JAMA) published a provocative piece that asked precisely that question. Shortly before publishing in JAMA, the authors, summed up their argument in a New York Times Op-Ed: “Always Hungry? Here’s Why.”  

There, David Ludwig, a professor of pediatrics at Harvard Medical School and director the New Balance Foundation Obesity Prevention Center at Boston Children’s Hospital, and Mark Friedman, vice president of research at the Nutrition Science Initiative did a superb job of distilling their argument into terms a layman can understand.

They suggest that chronic overeating represents a symptom rather than the primary cause of piling on the pounds. Indeed, Ludwig and Friedman argue, dieting itself may induce changes in our metabolism that leads us to regain weight when we begin to lose it.

They explain their theory:  When we eat hearty meals, “we lock . . . more calories away in fat tissue.” As a result, “fewer are circulating in the bloodstream to satisfy the body’s requirements.” In other words, there are not enough calories in our bloodstream to give us the energy to do what we want to do.

“If we look at it this way,” they continue, “it’s a distribution problem: We have an abundance of calories, but they’re in the wrong place. As a result, the body needs to increase its intake. We get hungrier because we’re getting fatter.” 

Ludwig and Friedman compare the process to what happens when patients suffer from “edema, a common medical condition in which fluid leaks from blood vessels into surrounding tissues. No matter how much water they drink, people with edema may experience unquenchable thirst because the fluid doesn’t stay in the blood, where it’s needed.

“Similarly,” they suggest, “when fat cells suck up too much fuel, calories from food promote the growth of fat tissue instead of serving the energy needs of the body, provoking overeating in all but the most disciplined individuals.”

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A RAND Report on “Workplace Wellness” Is Quietly Buried for Five Months—Why?

Did you know that in the U.S. “Workplace Wellness” has become a $6 billion industry?  That’s how much employers pay vendors who sell workplace wellness programs designed to encourage employees to lose weight, lower their cholesterol, or stop smoking..  

Today, firms lay out an average of $521 per employee per year on ‘wellness incentives’ such as gift cards for employees who shed pounds. That is more than double the $260 they spent in 2009 according to a recent survey by Fidelity Investments and the National Business Group on Health. 

 At first blush, this sounds like progress: Enlightened employers are doing their best to encourage employees to take care of themselves.  There is just one catch: we have no hard evidence that these programs either improve health or lower health care bills.

Even Bruce Elliott, manager of compensation and benefits at the Society for Human Resource Management, the largest professional organization that represents benefits managers, is concerned. As employers chase Wellness, “the one things that does worry me is the utter lack of metrics and really, the utter lack of thought” Elliott recently told Bloomberg News, pointing to the “herd mentality” that seems to have overtaken the idea of “workplace wellness.”  

      A Rand Report Appears Briefly Online—and Disappears                   

Two weeks ago, Reuters broke a story about a RAND report on Wellness programs that was supposed to come out last winter. The report was mandated by the Affordable Care Act, and RAND delivered the analysis to the U.S. Department of Labor and the Department of Health and Human Services last fall. 

 According to Reuters’ reporter Sharon Begley, “Two sources close to the report expected it to be released publicly this past winter.”  She added that “Reuters read the report when it was briefly posted online by RAND before being taken down because the federal agencies were not ready to release it, said a third source with knowledge of the analysis.”

RAND had collected information about wellness programs from about 600 businesses with at least 50 employees and analyzed medical claims collected by the Care Continuum Alliance, a trade association for the health and wellness industry.

Reuters revealed that the results were disappointing:  “The programs that try to get employees to become healthier and reduce medical costs have only a modest effect. Those findings run contrary to claims by the mostly small firms that sell workplace wellness to companies ranging from corporate titans to mom-and-pop operations.”
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