Doctors need to badger more or less?

Published 7.16.2017
On a population level, people continue to get and stay obese, and the question is how should doctors react? The answer to that question depends on where you sit on the obesity political spectrum— and yes, I do find the analogy to politics more convincing than the religious analogy I've seen used. However, further discussion would be a digression from my point here.

Some believe that their number do not sufficiently confront patients who are unknowingly obese. Or perhaps trending that way for a few years. The answer is that doctors need to badger obese patients more. If you read much in the health at every size (HAES) or body positive (BoPo) social media, you’d get the impression that the only issue doctors ever address is the patient’s obesity.

To overcome the stigma associated with obesity, Dr. Lazarus recommended opening the conversation and using person-first language (e.g. refer to a “patient with obesity,” instead of an “obese patient”). This can be performed if physicians begin to look at obesity like diabetes—there’s pre-obesity and obesity. It isn’t two separate diseases, but similar to diabetes, it allows physicians to provide measures to prevent obesity. By choosing the right approach, physicians can begin to address obesity with their patients without feeling uncomfortable.

The claim is that 50% of people don’t even know they have it. And here is where the conflation of overweight, obese and morbidly obese cause problems. When I was 50 pounds heavier I fell into the obese category, but only by a hair. I was certainly pudgy, but I don’t know that I would have described myself as obese. Yet technically, I was. I was also overtly healthy using most common markers.

I don’t think I would have reacted well if my doctor had started haranguing about obesity at that point. The issue is when does the excess weight begin to adversely affect health? If you’re 100+ heavier than the weight range optimal for your height and age, but are otherwise mobile and healthy, shouldn’t a doctor approach you differently than someone whose weight has begun to diminish their health?

Dr Arya Sharma prefers using that yardstick to determine whether an obese person requires active treatment. However, Sharma also wants obese people to think they are helpless to change their condition. Sharma analogizes maintaining weight loss as equivalent to scaling Mount Everest— which is insulting to the people who train and make that arduous trek. All losing weight and maintaining it takes is reducing the amount you ingest and/or becoming more physically active. It really is that simple. It may not be easy, changing habits usually isn’t, but in no way is it akin to scaling the highest peak on the planet.

Yes, there are endocrine systems involved in the digestive process, and yes the body adapts to changes in food intake. But to assert that the body can’t adjust its set point is simply false. I adjusted mine, and plenty of others have done so as well. But you can’t do so without a permanent change in habits.

Sharma and his ilk create a self-fulfilling prophecy of failure for dieters, and that’s simply not true. What is true that isn’t one single way that works for everyone. What will work for you is whatever you can live with the rest of you life. If that’s low carb high fat diet, kudos. If it’s high carb low fat, great. If it’s simply adjusting your portions sizes of everything, congrats.

The bottom line remains: to lose weight you must adjust your energy balance. This takes time, but it can be done. In fact, there are studies proving that it can be done and that the set point can be adjusted. It’s not just my anecdotal evidence.

The main finding in the study revealed that after one year of successful weight loss maintenance, the researchers were able to demonstrate that postprandial levels of two appetite inhibiting hormones (GLP-1 and PYY) increased (=appetite inhibition) from before-weight loss level -- in contrast to the hunger hormone ghrelin, which increased immediately after weight loss but returned to normal levels (= low hunger) after one year. This demonstrates that the hormones GLP-1 and PYY are able to adjust to a new 'set point' and thus may facilitate the continuation of a new and lower body weight.

These results are from a 2017 meta-analysis (for the record, I’m not a huge fan of meta-analyses because they usually compare apples and oranges and try and draw overriding conclusions) decided that the evidence is that calorie restriction reduced cravings over time. Cravings are by definition a subjective measure, a bit like pain. Both are real, but both are nearly impossible to measure and are perceived differently by each individual.

If the body is used to eating certain things at certain times, it can take some time to alter that pattern. But if you stick with it through the adjustment period, again, the body adapts. The notion that never, at any time, should a person experience any sense of deprivation needs to be refuted. If you're used to eating 1000+ calories than a body of your height and age should eat (and if you are large enough you may very well be eating that much in excess), then yes, it's going to be a physical and mental adjustment to a smaller food allotment. Difficult should not mean impossible.