DEB ATE: OBESITY 1
An ethical approach to obesity Robyn Toomath Clinical Director of the Internal Medicine Department, Auckland City Hospital
Our current approach to obesity isn’t working. Not only are we becoming fatter despite our efforts but an emphasis on education and motivation implies that we can change our weight if we choose to. Not only is this stigmatising, it is factually incorrect. As doctors we need to debate the ethics of asking our patients to lose weight. As a society we need to consider the harm caused by making obesity an issue of personal responsibility. We need to re-frame obesity as a ‘whole of society’ problem to find justifiable solutions.
© Journal of holistic healthcare
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Having trained and worked as an endocrinologist I now work largely as a general physician. In 2001 while President of the New Zealand Society for the Study of Diabetes I co-founded the advocacy group Fight the Obesity Epidemic (FOE) campaigning for public health measures to end obesity. After hundreds of radio and television interviews I decided I needed to write a book. In 2016 Auckland University Press published Fat Science: Why Diets and Exercise Don't Work – and what Does. By describing the true drivers of obesity, my hope is that people who struggle with their weight will be empowered and join public health activists to demand a healthier environment in which to live.
While training in endocrinology I worked in diabetes clinics where patients routinely had their blood sugar and weight measured on arrival. These were recorded in the invariably large, cardboard-covered, medical records. Some of the patients had records going back decades. This was before diabetes had become so common that general practitioners were thought competent to manage the problem. Back then everyone with type 2 diabetes came to a specialist clinic for prescriptions of metformin and sulphonylureas and the unvarying advice to lose weight. I liked flicking back through the years and recognising the handwriting of my older colleagues and occasionally myself as a junior doctor. Most interesting, however, were the weight recordings. Although there were short-term fluctuations the pattern was one of remarkable stability. When patients are first referred to clinic they are usually determined and enthusiastic and most will lose weight on learning the role that excess abdominal fat plays in glucose intolerance. A 5–10% drop in weight was common. But by six months it would start to creep up again and by two years even quite large amounts of weight lost would usually be regained.
Volume 13 Issue 2 Summer/Autumn 2016
Setting patients up to fail? Recommending a course of treatment with only a small chance of success wouldn’t be so bad if it was framed this way from the outset. Cancer specialists do this all the time and their patients then make an informed decision to try the therapy or not. Imagine if we said to our patients ‘you can try weight loss. It would be really helpful if it worked but there is an 85% failure rate’ (Ayyad and Andersen, 2012). Many might decide they’d rather avoid the misery of dieting and accept the inevitable; or try to improve their health in other ways. But we not only fail to give realistic expectations, we do something worse. We place all the responsibility for treatment success or failure on our patients rather than ourselves, AND we imbue the treatment success with value not normally associated with effective medicine. Years after I decided not to recommend losing weight as a treatment option I had to stop myself from celebrating weight loss when it occurred. The flipside of congratulations for weight loss is disapproval of weight gain. People with diabetes are constantly judged for their compliance with blood sugar testing regimes and dietary restrictions. I figured the last thing they need was
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