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I have to thank my colleague Michelle May, M.D., CSP for recently posting links to two articles that I had missed in the past. Both were very interesting. But what I found really fascinating was the way they worked together.
The first article she posted was in the BMJ (formerly the British Medical Journal). It was an editorial article written by Emma Lewis entitled “Why there’s not point in telling me to lose weight”. In this poignant piece, Emma talks about how no matter what she goes to the doctor for, she’s told she needs to lose weight. She talks about the fact that her health markers are good and how she exercises regularly and strenuously. She talks about the fact that doctors often tell her to start exercising, without even asking if she is exercising already.
Emma also talks about how her doctor’s “one-size-fits-all-fatties” approach to wellness makes her feel alienated, unheard, and shamed. And she talks about how it keeps her away from doctors–how she hasn’t been to see her GP in a while, how she’s not doing routine diagnostic stuff.
This article is in a section of the BMJ called “Practice: What Your Patient is Thinking”. I applaud BMJ for running this piece. But I have to fight despair when I read the comments.
The comments are not uniformly bad. There are a few doctors that get it. But lordy, lordy, LORD there are quite a few that don’t. I’ll summarize some of it so you don’t have to waste the sanity points reading the comments yourself. But most of them go something like this:
1. The Super Snarker: Well if the fatties don’t WANT to change, then she’s right–there’s no point telling them to lose weight.
2. The Concern-Trolling Hand Wringer: But it would be irresponsible for me as a DOCTOR to not bring it up. Maybe they don’t know they are fat. Maybe they don’t think fat is bad.
3. The Food Policer: Well yeah, she exercises. But exercise doesn’t make people lose weight. She just has too much hunger.
4. The Math Guy: Well of course she can lose weight. Energy in vs. energy out! Look it worked in concentration camps and lands with famine so it’s just math.
5. The Apocalypser: Obesity is bad. Everybody Panic! Cuz’ FAT!
Like I said, there are some that point out that Emma has a point. There are some that get the fact that she feels unheard and disrespected and that this is a problem. But virtually everybody who commented seems to believe that Emma’s main problem with weight loss is a problem of will. If she wanted to, she could be skinny.
Except the evidence is not in favor of this hypothesis.
We simply don’t know any way of helping any but a very small percentage of people to lose a significant amount of weight and keep it off. We just don’t. And for any weight loss intervention we undertake, a very small percentage of people lose some weight and keep it off, the vast majority of the people gain all the weight back and a significant percentage of those people end up bigger than when they started. And a whole lot of people end up facing serious negative financial, social, medical and psychological side effects from the whole process.
And we simply don’t have enough evidence from the very small percentage of people who lost the weight and kept it off to determine, if even that tiny percentage of people end up healthier because they lost weight. We know that most people who exercise and eat better experience health benefits regardless of whether or not they lose weight. But we don’t know if fat people who become skinnier are healthier in the long run.
So all five of the commenter types above are missing a few very important points:
1. There is no intervention that you can offer Emma that offers her any kind of reasonable chance for significant, long-term weight loss. In fact, statistically, just about any kind of intervention you offer is statistically more likely to make Emma bigger in the long run than to make her smaller.
2. Any intervention that you offer Emma is likely to have negative side effects. These negative side effects include physical, social, financial, emotional, relational, and physical problems.
3. You can offer no reliable evidence that, should Emma be one of the very few people to achieve long-term, significant weight loss, she will experience health benefits from the weight loss that she would not achieve from far less invasive wellness efforts with far fewer side effects.
Cue the second blog post shared by Michelle May.
This post called “Let’s Talk About Intentional Weight Loss and Evidence-Based Medicine” is found in the blog entitled Worse for the Fishes by Anna G. Mirer, M.P.H. In this wonderful post, she talks about all of those wonderful interventions available to the five classes of point-missing commenters above. She talks about how they don’t work. She talks about how they cause more problems than they solve. She talks about how there’s no real evidence that they help anybody. And she provides lots of links to back this up.
I’m sure that this will all be refuted by another special kind of commenter:
The Research Refuter: Despite the fact that there is massive amounts of evidence supporting what you say–amounting to hundreds of peer-reviewed studies in reputable journals, I don’t like your evidence. Therefore I will accuse you of cherry-picking your articles.
Again, I have to thank Michelle for bringing these two articles together in my world at the same time. It so perfectly illustrates how we as a society are perceiving the wrong things as the problem and thus suggesting the wrong solution.
To me the solution is simple:
1. Everybody benefits from eating well and exercising, along with managing stress, sleeping well, and having strong social relationships.
2. So medical professionals just ask if people need any support with eating well, exercising, managing stress, sleeping well and having strong social relationships.
3. If people say no, then stop. If people ask for help on any of those specific behaviors, offer help with those behaviors.
Jeanette DePatie (AKA The Fat Chick)
P.S. Want me to come and talk to your group about evidence-based medicine and wellness? Send me an email at jeanette at the fat chick dot com.
P.S.S. You can learn more HERE.