Weight-An Ill-Fated New Year's Resolution
From Radiance Spring 1998
When I read the editorial "Losing Weight-An Ill- Fated New Year's Resolution" in the January 1, 1998, New England Journal of Medicine, I thought surely I must be hallucinating. Size acceptance activists and wise health professionals have said for years that the risks of being fat and the benefits of weight loss have been exaggerated in both medical and popular media. They've warned that America's obsession with thinness, coupled with the dieting and the weight-loss drugs recommended by obesity researchers, are harmful, not helpful. But now those concerns are jumping off the pages of one of the world's most conservative and prestigious medical journals, where its readers (some of our own doctors) will, perhaps for the first time, understand that these are serious issues worthy of serious examination. This is a big deal, friends.
With thirty-six scientific references backing them up, NEJM editors Jerome Kassirer, M.D., and Marcia Angell, M.D., challenge an all-too-familiar scenario: "Today, at the start of the new year, millions of Americans will resolve to lose weight, but by tomorrow, or next week, or maybe next month, most of them will have given up trying," they begin. "Few will have lost weight, and even fewer will sustain the loss. . . . They buy low-calorie and low-fat foods, deny themselves dessert, drink only artificially sweetened beverages, join commercial weight-loss clubs . . . take diet pills . . . submit to liposuction, and exercise obsessively to burn calories. . . . The goal is to reach the elusive American ideal-to be slim, fit, and forever young.
"But there is a dark side to this national preoccupation. Since many people cannot lose much weight no matter how hard they try, and promptly regain whatever they do lose, the . . . money spent . . . is wasted. More important, failed attempts to lose weight often bring with them guilt and self-hatred. . . . To add insult to injury, the latest magical cures are neither magical nor harmless." Kassirer and Angell then detail the risks of diet drugs and fat substitutes and describe the tragic epidemic of dieting and eating disorders among girls and young women.
They go on to address assumptions commonly held by both medical practitioners and the public: "Given the enormous social pressure to lose weight, one might suppose there is clear and overwhelming evidence of the risks of obesity and the benefits of weight loss. Unfortunately, the data linking overweight and death, as well as the data showing the beneficial effects of weight loss, are limited, fragmentary, and often ambiguous. . . .Although some claim that every year 300,000 deaths in the U.S. are caused by obesity, that figure is by no means well established" and is based on "weak or incomplete data."
For these authors to call the 300,000 statistic into question is critical. That number appears in almost every research or press article about the supposed health emergency due to increasing numbers of fat Americans. What's important for readers to know is that the 1993 study by McGinnis and Foege (reported in the Journal of the American Medical Association, 1993, vol.270. Actual causes of death in the United States), which is the source for this number, actually found inactivity and poor nutrition, not weight per se, as contributing factors to death. This distinction is rarely made. Nevertheless, this number was used in the argument to justify hasty FDA approval of Redux, the diet drug subsequently recalled for causing cardiac damage, a real public health disaster. Dr. C. Everett Koop's Shape Up America! (whose funders and sponsors have included Weight Watchers, Jenny Craig, Slimfast, and the distributors of Redux) uses the number to try to convince doctors to further pressure their patients to lose weight, by bringing up weight loss at every visit (as if many doctors don't already do that). The Koop campaign and obesity researchers have already reacted to the NEJM editorial with blustering press releases and outraged letters. But the NEJM has also been congratulated for its courageous stance-by no less than the Advancement for Sound Science Coalition in Washington, D.C.
Kassirer and Angell do not dismiss the health risks of higher weight completely. ". . . [E]vidence suggests that as weight increases, so does mortality (premature death) but only modestly. . . . We simply do not know whether a person who loses 20 pounds will thereby acquire the same reduced risk as a person who started out 20 pounds lighter." The authors say that "being substantially overweight" is associated with heart disease, high blood pressure, diabetes, and a variety of musculoskeletal problems, and that losing 10 to 15 percent of body weight can improve these conditions. They advocate "measures to prevent obesity" and propose that if children were more physically active instead of eating junk food in front of the TV, "leanness would be virtually ensured." Well, not really. It is likely that children and adults of all sizes would feel better and be healthier with more physical activity and less TV and junk food. But people naturally come in different shapes and sizes. The authors verify this themselves by citing research on set-point theory and genetic research, saying "hereditary factors play an important part in a person's weight."
In what I believe is the editorial's strongest point, the authors ask, "Given the ambiguous benefits of weight loss, why are physicians and public health officials joining in the general enthusiasm for losing weight? . . . [A]s we have seen, losing weight and sustaining the loss are not nearly as easy as they sound; the benefits may be quite limited, and the risks of some methods may be large." Then they get to the crux of the matter: "[T]he medical campaign against obesity may have to do with a tendency to medicalize behavior we do not approve of. . . . [O]bese people can be criticized with impunity, because the critics are merely trying to help them. Some doctors take part in this blurring of prejudice and altruism by overstating the dangers of obesity and the redemptive powers of weight loss." The authors also criticize those who take the strict biological stance that obesity is no more within a person's control than eye color. In summarizing these two perspectives, Kassirer and Angell conclude that "either way, the result is to see overweight people in medical terms, rather than as ordinary people who happen to be heavier than average, probably from some mixture of nature, nurture, and choice."
Finally, they suggest that doctors tailor any weight-loss advice to the individual patient. "Many overweight persons are happy and in reasonably good health, some overeat because they are depressed, and still others are depressed because they are overweight. . . . [D]octors should provide advice if an overweight patient asks for help in planning a weight loss program and recommend weight loss if a patient is suffering from health problems that can be ameliorated by weight loss, such as hypertension, [or] diabetes. . . ." The quote from the editorial that appears most frequently in the press sums it up: "Until we have better data about the risks of being overweight and the benefits of trying to lose weight, we should remember that the cure for obesity may be worse than the condition."
Kassirer and Angell urge doctors to "do their part to help end discrimination against overweight people in schools and workplaces. . . . [S]peak out against the public's excessive infatuation with being thin . . . [and] help the public regain a sense of proportion."
While I can shout Amen! to this idea, my focus as a health specialist is on action to improve quality of care for large people. For that to occur, doctors must also examine their own attitudes and work to reduce discrimination in medical care. The editorial did not specify what advice doctors should offer patients with conditions such as diabetes or high blood pressure. No research demonstrates that these people have any better track record at maintaining weight loss than anybody else. We must shift the focus from weight loss to health improvement. when I was a regional health education consultant at Kaiser Permanente (1989 to 1997), our education program for doctors urged them to assess an individual's medical history and prior attempts at weight loss, and then explore how the person could begin to make small, steady changes. Positive changes-being more active on a regular basis; eating nutritious food and satisfying one's hunger rather than dieting and obsessing about food; managing stress; increasing positive social support-can improve health whether weight is lost or not. Many doctors have found this approach much more successful than the traditional focus on weight alone. But patients must shift their focus as well. People have to stop begging doctors for weight-loss miracles. Many doctors prescribe diet pills simply because of relentless patient demand. There is simply no substitute for positive self-care and education about one's own health. Any weight loss that does occur will not be the stuff of "before" and "after" pictures, but a side effect of life-style changes that must be maintained for health improvement to be maintained. No magic. No miracles. But better health to be sure.
Everyone deserves respectful treatment by doctors and by society. It is my hope that this thoughtful editorial and whatever debate it invites will help doctors and those who seek their help to stop seeing weight as the most critical factor in their health, and to focus instead on healthful living regardless of size. Working toward this goal is a New Year's resolution that is long overdue.
Look for the editorial in your library: Jerome Kassirer and Marcia Angell. New England Journal of Medicine. Jan. 1, 1998, vol. 338, no. 1, pp. 52-54. Or look for it on the Web @ www.nejm.org. �
PAT LYONS, R.N., M.A., is coauthor with Debby Burgard of Great Shape: The First Fitness Guide for Large Women and director of CONNECTIONS Women's Health Consulting Network, based in Oakland, CA. She is a program development specialist and a popular speaker at women's health, nutrition, fitness, and wellness conferences and community events.
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