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A Moral Code Against Obesity Care?

Why is it so difficult for a person with obesity to find evidence-based care from a knowledgeable physician? For insight, read the moral code for obesity care presented by Gordon Schiff in the latest issue of the New England Journal of Medicine.

Schiff advises for exclusive reliance on prescriptions of diet and exercise. He recommends never using obesity medicines, “even in the case of patients who can take such medications without unacceptable side effects.” Explaining his convictions, he says:

These drugs violate nearly every principle of careful, conservative prescribing, and they may well put patients at risk.

Schiff’s generalizations are so broad that he barely mentions the patient, Ms. Chatham. Responding to the case presentation, Joaquin Diaz-Mediavilla offers this unhelpful prescription:

It’s very simple: in my opinion the solution is to not eat. A person can eat enough, eating once a day. The food will consist of salads and vegetables in abundance with low protein and very small amount of fat and carbohydrates.

To be sure that the system works, the patient should be weighed every day, early in the morning, and is forced to reduce at least 300-500 grams of weight every two days.

Robert Kushner, a past president of the Obesity Society, steers clear of the moral code and simply says:

Ms. Chatham is a candidate for adjunctive pharmacotherapy in addition to lifestyle modification to assist in her weight management.

The use of pharmacotherapy enables patients to adhere to a dietary plan that includes a reduction in calories and to do so with better control and a reduced sense of deprivation.

For now, the moral code is winning. The non-scientific poll on the NEJM website registers more than 80% of respondents in favor of nonpharmacologic therapies. A research letter in the same issue sums up the prevailing bias. Elina Helander, Brian Wansink, and Angela Chieh offer a strategy to prevent holiday weight gain:

Advising a patient to have better self-control over the holidays is one approach.

Unfortunately, moralistic scolding about obesity seems to be what’s most commonly dispensed. If you need evidence-based obesity care, your best bet is to look up a physician who has invested the time to actually learn about obesity and earn certification  from the American Board of Obesity Medicine. A registered dietitian with expertise in weight management can also be a big help.

Scolding is less helpful and often available for free from relatives.

Click here to read the case vignette and commentaries. Click here to read the research letter by Helander, Wansink, and Chieh.

Arrows, photograph © Dean Hochman / flickr

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September 25, 2016

6 Responses to “A Moral Code Against Obesity Care?”

  1. September 25, 2016 at 11:47 am, Joe Gitchell said:

    Thanks, Ted. It is so easy to succumb to the allure of simple and virtuous. Sounds akin to this discourse on e-cigarettes and quitting smoking:

    http://www.nejm.org/doi/full/10.1056/NEJMclde1602420#t=article

    Joe

  2. September 25, 2016 at 12:31 pm, Ted said:

    Health gets confused with virtue so easily…

  3. September 25, 2016 at 10:39 pm, Adam Tsai said:

    I know Gordon Schiff from the single payer health care advocacy movement and he is a good person. It is a shame that he doesn’t understand the complexity of obesity and gives the same simple prescription. My experience has been that when docs learn about the biological adaptations that occur with weight loss, they are more open to using medications and surgery to treat obesity

  4. September 26, 2016 at 4:35 am, Ted said:

    Thanks, Adam. I really appreciate your perspective and agree with the sentiment.

  5. September 26, 2016 at 2:19 pm, Tammy Beaumont said:

    Disappointing on so many levels….. Especially Brian Wansink’s comment. :((

  6. September 27, 2016 at 10:48 am, Allen Browne said:

    :(((((