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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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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