Why weight loss advice may be unethical

And issue of Newsweek quotes me as saying, “A lot of our weight-loss recommendations are unethical because we shouldn’t be saying lose weight when there is no chance people will keep it off.“

This quote appears in the context of a lengthy article by Daniel Heimpel that examines whether or not the obesity epidemic is being oversold.

While I personally do not think that the obesity epidemic is being oversold, I do stand by my statement that most of the weight loss advice given to patients with overweight or obesity is unethical.

In medical school, I was thought the principle of “primum non nocere” or “first, do no harm.” This principle begs us to always consider the possible outcomes (including the unintended ones) of any actions that we take with our patients, including of course the advice we give them.

So what are the potential ethical concerns about telling someone to lose weight?

1. The way this advice is presented. It is certainly no secret to the readers of this blog that weight-bias is widespread, not least amongst health professionals. As a result, the weight issue is not always addressed in the most sensitive or professional manner, thereby often resulting in little more than having the patient cancel all future appointments.

2. The advice that is given is of little help. As most health care professionals lack even the most basic understanding of the sociocultural, psychological and biological determinants of energy regulation, they generally boil this down to “less energy in and more energy out” or “eat less, move more”. Most physicians will in fact primarily recommend exercise, actually the least effective method to lose or control weight. Patients, who recognize the futility of this advice (most often because they’ve been there and done that), are likely to have less confidence in their physicians’ recommendations, even in areas in which the physician may well be competent and knowledgeable. This can clearly have a negative impact on the patient-doctor relationship.

3. Rates of recidivism or weight regain are virtually 100%. In general, interventions, where the rate of recidivism is that high (especially in severe obesity, with the exception of bariatric surgery), should be recommended with caution. Weight loss takes time, resources, motivation, and dedication, and despite the best intentions and early success, the vast majority of patients will regain any weight they lose and, in some cases, end up heavier than before. This setback generally comes at a cost, if only a diminished motivation to ever address this problem again. This state of affairs is by no means made any easier by the fact that most patients (and physicians?) will ultimately put the full blame of failure on themselves (on the patient) – another blow to an already low self esteem.

4. Unhealthy weight loss strategies. Patients, who do take the advice to lose weight seriously, are generally left to do so of their own device. This opens the field to all manner of commercial and non-commercial weight loss products and services, little of which has any proven long-term efficacy (the only weight you lose in the long term is the weight of your wallet). Without proper guidance and surveillance by licensed and trained health professionals (like for any chronic disease), chances are high that patients will make the wrong choices, thereby setting themselves up for failure and frustration with a high likelihood of ultimately only making things worse than better.

5. Lack of hard evidence of benefit. Believers in “evidence-based” medicine should listen carefully: there is to date no evidence whatsoever that intentional weight loss (short of bariatric surgery) will lead to a reduction in “hard” outcomes (heart attack, stroke, death). Any evidence on health benefits is limited to improvements in surrogate measures and risk factors or to “soft” outcomes like quality of life. While these are certainly important, we need to realize that any promise of a longer life with weight loss is premature and not based on any hard outcome trials. As a result, we need to be very clear with ourselves and our patients that currently, the best we can expect is indeed an improvement in co-morbidities and perhaps in quality of life – there is, however, as yet no guarantee that weight loss will actually increase the likelihood of playing with your grandchildren.

I will spare my readers the fascinating discussion on the increased rates of depression and even suicidality that has been observed in some weight-loss studies.

It should be clear from the above, that the often well-meant but lightly given advice to simply “lose a few pounds”, when presented in the wrong manner, the wrong setting,  and/or without professional guidance or support, has the potential to do more harm than good and should therefore not be nonchalantly offered to all patients with overweight or obesity without a careful consideration and discussion of pros and cons as well as likelihood of success.

Remember, as blogged before, successful weight management starts with limiting further weight gain.  It’s a much more achievable and sustainable goal than losing weight and keeping it off.

Arya M. Sharma is a Professor of Medicine at the University of Alberta who blogs at Dr. Sharma’s Obesity Notes.

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  • http://www.facebook.com/theresa.palomares Theresa Tee Thompson Palomares

    Right on! And what about all the crap that was on the news last week about Obesity causing recurrence in breast cancer! Now the general public makes the assumption that just because you are overweight, you contributed to your own cancer! I was on the Forks Over Knives blog the other day and some guy was lecturing me about my petition for stage 4 mets and said we wouldn’t have mets if we ate right! How much more stupid is it going to get!!!

  • Mary

    What about the fact that nutrition isn’t taught in medical school, and the nutritional guidelines that exist are heavily influenced by food corporations? Like “6-11 servings of grain per day”…ever tried losing weight by eating a loaf of bread daily?

    • bob

      In fact, yes – but that’s because I’m a powerlifter. I dropped 15lbs of fat in 3 months while eating around 2800 cal a day so that I could make weight at a powerlifting competition. But then again my stats are abnormal. At 5’11″ and 230lbs, I’m regarded by the BMI scale as being obese even though I pack on a huge amount of muscle. I can pick up 600lbs off the floor without breaking a sweat, squat 650lbs, and bench 400lbs. I also eat about 7000 calories a day when bulking up.

      But regardless, regular joes and jills on the other hand lack the ability to pull of what strength athletes and bodybuilders can do because they 1) Lack the dedication and drive to stick with workout plans, and 2) Have no idea what the term “exercise” really means. In regards, to number 2, fast walking on the elliptical for an hour, or following the stuff that celebrity trainers (who know very little of anything about strength and cutting fat) is not effective: There is no other substitution for hard barbell training to build muscle, and a fat cutting routine of hard cardio combined with barbell training for muscle maintenance. This is an insight derived from the last 60 to 70 years of powerlifting and bodybuilding by coaches and athletes.

      Good luck telling your patient to do this though. Or even getting them to go to a gym for more than a week.

  • http://www.facebook.com/kathy.wire Kathy Kottemann Wire

    I don’t disagree, but do think that medical professionals could encourage the BEHAVIORS that can lead to weight loss and which are otherwise generally healthy. First, focus on eating reasonably health food. Second, avoid a sedentary lifestyle. Once you start waking across the parking lot and taking the stairs, it gets easier. For overweight patients, logging food can have a tremendous impact. I lost 15% of my highest body weight 4 years ago because I started logging food/calories for another reason. When you have to come face-to-face with everything you eat, and decide you want to eat it, losing at least the first five or ten pounds is not too hard. I have read that continued logging of food is the most common habit among successful long-term losers, and that has been my experience. By focusing on simple behavior change and not the weight itself, I think we allow people to make their own decisions but with full knowledge of the immediate consequences.

    • Arya M. Sharma, MD

      You’re on the spot Kathy – we should focus on behaviours – weight loss is not a behaviour, at best it is the outcome of a behaviour. Eating a healthier diet and getting more exercise will benefit you, irrespective of whether or not you lose weight. Self-monitoring by keeping a food diary can help you eat better and if you lose weight that’s great – if not, you’re still probably eating better than before. Healthy eating is about nutrients, losing weight is about calories.

  • http://www.facebook.com/sharon.hayesrateike Sharon Hayes Rateike

    Excellent write up! This is exactly the type of information that needs to be publicized more so individuals start to understand that there is more to a weight loss than just weight! Advising people to be healthy by losing weight is one of the biggest misconceptions there is regarding wellness! And being at a healthy BMI does not guarantee your reduced risk for chronic disease and conditions.

    • Jake

      Re: “And being at a healthy BMI does not guarantee your reduced risk for chronic disease and conditions.”
      On what planet?? So you’re saying someone with a healthy BMI vs one of say 35, 40 or 50+ doesn’t have a reduced risk of developing type 2 diabetes?…not to mention the vascular, kidney and neuropathic sequelae?

      That logic is about as correct as saying that driving safely below the speed limit “does not guarantee your reduced risk for” being involved in a serious MVC. No, you’re not guaranteed to never be involved in a wreck, but if you spent one night in the ER and compared the outcomes for motorcyclists doing 120+ mph vs those in the fender-benders, you’d have your answer.

      Whether it’s BMI or mph, reckless behavior leads to bad outcomes.

      • Arya M. Sharma, MD

        Sure, if you have obesity related risk factors you may reduce your risk for CV disease (although data on this is actually far weaker than most people think). The point is that there are plenty of people, who despite eating as healthy as possible, regular physical activity and giving up smoking (which, btw is part of why they gained weight), may have little benefit from losing weight and may in then end just end up ‘yo-yo’ dieting themselves to even higher weights. Obesity is about as reckless behaviour as killing yourself is when you’re depressed.

    • Arya M. Sharma, MD

      Thanks Sharon – btw – I don’t know what a ‘healthy’ weight is. I have patients, who at a BMI of 50 are healthier than a lot of people I see at much lower body weights. Just because you are losing weight doesn’t mean you’re getting healthier – a lot of people manage to stay pretty healthy despite their excess weight (fit and fat). We need a definition of obesity that is not defined by weight.

  • Elyaihu

    While exercise may not be the most efficient way to lose weight, it is often protective against the diseases that are often associated with overweight and obesity. I dont understand why patients and doctors get so fixated on Numbers/BMI that they would rather a patient starve themself to an equally fatty and unhealthy lower weight rather than risk an exercise recommendation that wont yield rapid or magical results.

    • Arya M. Sharma, MD

      I don’t think it is about risking exercise recommendations – it is more about raising false expectations. If a patient begins exercising to lose weight and doesn’t, he stops. If a patient understands that exercise may not help lose weight but has plenty of other benefits, he may continue for the sake of those benefits. Incidentally, the role of exercise in obesity management has more to do with its effect on ‘energy in’ than on ‘energy out’.

  • http://www.thehappymd.com/ Dike Drummond MD

    An interesting spin Dr. Sharma. Don’t agree. It is not unethical to recommend weight loss for a hundred evidence based reasons you choose to ignore that are indeed based on quality of life. I also know you have a number of patients in your practice that have basically “cured” their type II diabetes and HTN with weight loss – as well as a number who have kept their weight off for decades without bariatric surgery. We all have a couple of them in our practice. Aren’t they an inspiration?

    So let’s set aside the false argument that weight loss doesn’t make a difference to the patient.

    What is true is that doctors are abysmal in inspiring the patient to lose weight and maintain that weight loss. In fact, we are perhaps worse than anyone else they could get professional weight loss advice from. This is for two simple reasons.

    1) On the surface … I hope it is clear that we are not trained to deliver and monitor an effective weight loss program. If we were, we would be doing it in every office across the country.

    2) At a deeper level, our patient’s weight is NOT OUR RESPONSIBILITY. It is a decision made by the patient every time they lift a fork to their mouth and every time they take a step (or don’t).

    We are advisors to our patients. We have an ethical responsibility to advise them of the consequences of being overweight and the truth about weight loss.

    There is no magic pill. No magic surgery or superfood.

    It is one less bite and 1000 more steps – done over and over and over again. It is a day to day decision to choose a lower weight and take effective action. It is not a pharmaceutical, or a LAP Band or hypnosis. It is us, supporting our patients making good choices and realizing — in our modern civilization of too many calories and too many opportunities to be entertained by doing things that do not burn calories — 90% and more will not be able to maintain an ideal weight.

    Does this mean we give up on the few who succeed? Does this mean we stop talking about it? That we stop telling the truth? THAT would be unethical.

    My two cents,

    Dike
    Dike Drummond MD
    http://www.thehappymd.com

    • Arya M. Sharma, MD

      You make some good points and I will not argue (nor did I in my post) weight loss can have benefits (although I’d never use the word ‘cure’ to describe the effects on diabetes or anything else). The point is that, when evidence shows that the recommended treatment (eat-less-move-more) will only work in a handful out of a hundred patients with the clear potential to do harm, then one has to be careful in any ‘off the cuff’ recommendations. If you have the time, training, and expertise to work with the patient – then by all means – if nothing else, at least acknowledge how difficult weight management actually is. For most obese people ‘simply’ eating less is about as easy as for depressed people to ‘simply’ be happy.
      AMS

      • http://www.thehappymd.com/ Dike Drummond MD

        Weight loss is a “cure” for diabetes and HTN in some patients. There is a weight below which they do not have the disease and above which they do. It is an obesity related illness and the obesity is a mandatory prerequisite to the diabetes and high blood pressure.

        Obesity is NOT a disease … it is a symptom of a set of habits that are supported by our modern society – two of the obvious ones are the calorie tsunami of modern food science and another is the epidemic of inactivity in all levels of society in the modern western cultures.

        To ignore obesity when the overweight patient is sitting right in front of you because – in the disease model – you have no “cure” … that magic pill that leaves you feeling god-like in rescuing them from their own sloth and gluttony – is missing the point completely.

        And there is a cure. It isn’t easy and it is painfully simple. Eat less, burn more. We must say it, shout it, emphasize it every chance we get and let our patients know they can create a permanent, therapeutic weight loss … because of the very existence of the few who have accomplished the feat. We do not have the ability nor the responsibility to control their weight. That is their part in their relationship with their own health.

        To say nothing is unethical.

        Dike
        Dike Drummond MD
        http://www.thehappymd.com

        • karen3

          Obesity is also a symptom of quite a number of diseases and a side effect of many medications. If your doctor is handing you 20 mg of prednisone for lupus and then turning around and giving you a lecture on weight loss, its really easy to start hating the doctor and thinking the doctor is a complete idiot. In which case you will not work as well with him in the case of the actual lupus treatment,

          Weight loss is far more complicated than eat less, burn more. I have severe gastroparesis, yet struggle with my weight. Why? I am an endocrine train wreck and getting everything in range at the same time (which is the only time I lose) is a very serious amount of work. I have gained weight at the rate of 20 lbs a month on 800 calories a day (Cushings, hypothyroid and growth hormone deficient). I have lost weight quickly eating like a pig and laying in bed (hyperthyroid). Maybe for those for whom calories in, calories out doesn’t work, some more thoughtful, probing questions are in order and a couple labs, before labeling them “non-compliant.” It really doesn’t take that much being off by a squidge to make weight loss hard.

        • http://twitter.com/cristinobrien Cristin O’Brien

          I can see the argument Dr. Sharma is making about not wanting to cause undue stress to a patient that feels powerless to alter their circumstances, but I agree with Dr. Drummond that the bigger point is missing – managing weight is a lifestyle choice. Yes, eat less and/or move more.
          As a physician you could view the advice as any other prescription and prescribe specific actions such as replacing two sodas with water every day, or trying to always take the stairs instead of the elevator. While these messagse are publically presented all the time, coming from a provider they have a bigger impact and are more likely to be followed. My bigest frustration with my mother’s cardiologist was when he told her it was ok to keep eating the way she was (a stick of butter every week is really NOT ok and goes a long way in explaining why she was 30+ pounds overweight). Since then I have been unable to convince her otherwise.
          So providers please, take an active role in prompting good behaviors when patients lack the motivation to do it themselves. Offer guidance and enable them to choose to live healthier. Be able to refer them to additional services such as a nutritionist, and be prepared to offer empahtatic support if a patient is frustrated and struggling with weight for medical reasons beyond their control (hypothyroidism, medications, etc.).
          If your patients refuse to listen, you tried. And for those that do listen, you’ve made a difference for your patients and a small step towards a healthier society.

    • http://www.facebook.com/jason.hazelett Jason Hazelett

      Dr. Drummond, well said. I have to agree with Dr. Sharma that the medical professional’s success rate at helping patients lose weight is poor. And yes, we need to be careful in our approach (love). Life expectancy, however, is not the primary goal. I never cease to be amazed at how candid longtime strugglers with obesity can be about their weight once they have taken true responsibility for it. I have numerous patients who have lost 50-200 pounds without my help. When I ask them how they did it, almost all reply with something frank like, “I quit stuffing my face.” An old co-worker of mine was over 350 pounds pretty much all her adult life, while yes, working as a physical therapist and telling others about health and movement. She is down to around 170 now. Her answer? “I stopped making excuses, learned how to eat right, and made myself do a few minutes of exercise every night before I left work.” Self-leadership is hard. If I have a health issue that I’m not overcoming, I hope my doctor doesn’t give up on giving me good advice just because the success rate is low or they might hurt my feelings.

      Jason Hazelett, PT, DPT

    • LaPortaMA

      The symptom is obesity. The disease is gluttony.

  • http://www.facebook.com/dkosnett Deborah Gibson Kosnett

    I have kept 80 lbs off 10 years. Instead of bemoaning so-called 100% recidivism, work on ways to help folks keep it off. Modern society’s knowledge of how to lose weight, and its expectations w/regard to weight loss and maintenance, are at odds with what’s really required. Education and retooling is what is needed.

    • Arya M. Sharma, MD

      Congratulations Deborah on doing this – your case proves the point I am trying to make – you are clearly an exception and just because you could do this does not mean that anyone can (believe me – they would). No one says its impossible (I have plenty of patients, who are keeping a lot of weight off) – I am just saying its hard and simply telling people to lose wieght as they walk out the door of your office is neither helpful nor effective.

  • Jane Infidel

    Interesting. You are right that simply saying, “lose weight, exercise more” is unhelpful. I read some of French Women Never Get Fat” and in her case the doc did actually spend time counseling her on weight loss. She saw a French doctor in France and he had her chart her eating habits. He saw that she would eat out a lot. She was grabbing French pastries in cafes every day. He told her to eat out less. She stuck to that diet and the weight came off. But not every doc spends time to ID the problem. They probably should. There are people who lost weight by cutting out soda and sugary drinks, but how many docs are actually going to take the time to recognize that and say, “The weight will probably come off if you cut out the daily soda and reduce it to once or twice a week.”

    • Mary Brighton

      Hi, I am an American dietitian living in France for the past 10 years. Doctors in France seem to spend more time with patients, seem less rushed. There is also a BIG push from the French government to keep obesity rates down and general practitioners are supported in their efforts to keep their patients from gaining weight.
      Mary@BrightonYourHealth.com

      • Arya M. Sharma, MD

        Glad to hear that Mary – obviously, preventing weight gain is far easier than preventing weight ‘re-gain’.

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    Interesting perspective but as a practitioner for 34 years I disagree. I have seen the gains and improvement in quality of life derived from a change in lifestyle that leads to improved eating habits, and an active lifestyle and accompanied by a weight loss that reduces the BMI to <30. Everything from lowering BP, to improving glucose metabolism and lipid metabolism to simply feeling better about themselves based on their hard word and discipline. The advice to change your lifestyle must be accompanied by specific plans and mechanisms to be successful including discussions of dietary changes, discussions of local practitioners who can provide dietary education and sound nutritional counseling, specific suggestions on methods to improve activity that the individual finds fun and enjoyable
    The road to success is not easy. The number of dropouts is large . The number of successes who maintain the healthy lifestyle is far less than we like. To not make the effort as a physician or health care provider is what is unethical. To not provide your patient with the information and tools they need to be successful is unethical. To not address the issue is immoral and unethical.
    I recently went on a physician recommended program and lost 52 lbs while my wife lost a similar amount. Our blood pressure improved. Our lipid profile improved. Our sense of energy improved. I have kept the weight off for the first six months since achieving my goal. I realize that maintaining the weight loss and healthy lifestyle will be difficult because stress and lifetime bad habits are tough to break. I thank my doctor for bringing up the topic and encouraging me to be successful. I will continue to encourage my patients to improve their lifestyle by eating healthy , being active and where appropriate lose weight. To not do so in the face of much evidence would be unprofessional.

    • Arya M. Sharma, MD

      Steven: “The advice to change your lifestyle must be accompanied by specific plans and mechanisms to be successful including discussions of dietary changes, discussions of local practitioners who can provide dietary education and sound nutritional counseling, specific suggestions on methods to improve activity that the individual finds fun and enjoyable” – I could not agree more and that’s the whole point of my article. Without such support the advice is ‘unethical’ – with such support, I’m all for it.

  • http://www.facebook.com/frank.ferrin.7 Frank Ferrin

    T
    he point being made is absurd. Of course you should not tell people with appropriate BMI to loose weight; but rejecting the premise that overweight individuals need counseling is preposterous.
    The main reason for the obesity epidemic is the lack of participation from health practitioners to endorse lifestyle changes and food consumption modification.
    This sounds like we should not tell people to save money just because they will POTENTIALLY go out and spend it later, anyway.

    • Arya M. Sharma, MD

      Frank – that’s not the point – there are countless people, who would benefit from losing weight (or not putting it on in the first place). The point is that as health professionals, we need to limit our advise to what actually works – simply telling people to lose weight does not! If you are serious about helping your patients lose weight then you better also provide them with evidence-based help to do so. Not following A with B makes no sense and can do more damage than good.

  • carolynthomas

    For those who continue to insist that advising patients to lose weight is simply a losing battle (and now even possibly unethical!) please consider the National Weight Control Registry which tracks people who have successfully maintained a weight loss over many years. This is the group we should be paying attention to.

    And when Consumer Reports National Research Center surveyed over 21,000 people earlier this year on lifetime weight/diet history, comparing those who have always been naturally slim with those who were overweight and who had deliberately lost weight, their results were actually encouraging (and in contradiction to your point #4 here). For example: “More than half of our successful losers reported shedding the
    weight themselves, without aid of a commercial diet program, a medical
    treatment, a book or diet pills. That confirms what we found in our last
    large diet survey in 2002, in which 83% of ‘superlosers‘
    – people who’d lost at least 10% of their starting weight and kept it
    off for five years or more – had done it entirely on their own.” More on this at: “Heart-Healthy Weight: Secrets of the Always Slim” –

    http://myheartsisters.org/2011/06/22/secrets-of-thin-people/

  • http://twitter.com/DrSherryPagoto Sherry Pagoto

    Interesting piece but I’m afraid it will be misinterpreted. I wish you had mentioned the efficacy data for lifestyle interventions (nutrition and exercise counseling with behavioral modification) per the Diabetes Prevention Program and Look Ahead studies, which demonstrate impact on many important clinical endpoints. And I wish you had strongly underscored the need for such resources to be accessible. To the extent that these are widely available, physicians can give advice because then they would have an evidence-based referral. I don’t think the reader will realize just by reading your post that there are evidence-based interventions but they just aren’t available. Your post suggests that no such evidence-based interventions exist. That is simply not true.

  • LaPortaMA

    If it’s standard, you do it and document it. Try not to and see what happens.
    HOWEVER, we as a society and a profession don’t even scratch the surface when it comes to understanding the significance of our patients’ conditions, so it’s not surprise our successes are few and far between and we have a hard time measuring…what?

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