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http://bmj.bmjjournals.com/cgi/content/full/309/6955/655
BMJ 1994;309:655-656 (10 September)
Education and debate
Controversies in Management: Dietary treatments for obesity are
ineffective
C S Wooley, D M Garner
University of Cincinnati, College of Medicine, Cincinnati, Ohio 45267,
USA Beck Institute for Cognitive Therapy and Research, Bala Cynwood,
Pennsylvania 19001, USA Correspondence to: Dr Wooley.
It is surprising that debate continues about the effectiveness of
dietary treatments for obesity. Perhaps this is partly related to
ambiguity in the term effectiveness. It is well known that most
treatments produce temporary weight loss. But it is equally well known
that 90% to 95% of those who lose weight regain it within several
years.1 This poor outcome has led to charges that traditional
treatments for obesity should be abandoned and countercharges that it
is irresponsible to withhold treatment for such a serious problem. The
failure of reducing diets to produce lasting improvement was recently
reiterated at a National Institutes of Health consensus conference,
which also warned about the adverse effects of treatment.2
The failure of fat people to achieve a goal they seem to want - and to
want almost above all else - must now be admitted for what it is: a
failure not of those people but of the methods of treatment that are
used. It is no longer a mystery why diets have such a poor long term
record of success. Indeed the failure of obese people to become or
remain thin by "normalising" their food intake follows logically from
studies on the heritability of obesity,3 the biology of weight
regulation,4 and the physiology of energy metabolism.5
Demand for treatment is not a justification
Yet many remain enthusiastic about treatment. It could be said that the
main evidence for the value of dieting is that health professionals
continue to prescribe it. Inertia feeds on itself, failure to change
coming to serve as a silent argument that no change is needed. However,
this only partially accounts for the resistance to change among those
treating obesity. Recent findings regarding the benefits of antibiotics
in treating ulcers and the comparative outcomes of procedures for
emergency cardiac care have been rapidly translated into medical
practice. In these cases doctors have only had to adjust what they do;
in the case of obesity treatment, however, there is no replacement
procedure. The question is whether to abandon treatment, putting many
specialists out of business, in the face of relentless popular demand.
Desperate consumers are willing to bear the burden of responsibility
for failure in exchange for continuing access to treatment. This
desperation is best illustrated by Ravitch and Brolin's observation
that patients who had had obesity surgery were unwilling to consider
reversal even when it was discussed in terms of saving their lives.6
As if to avert the central question by introducing more variables, the
debate has shifted from the universal mandate for one treatment, to the
matching of available treatments (from self directed programmes to
surgery) to individual, depending on level of obesity and factors such
as diet history.7 Notably, even for patients as little as 5% overweight
the option of withholding weight loss treatment does not appear on the
decision tree. Wadden has argued that the "no treatment" option "cannot
be universally endorsed until there are definitive research data."8
This is an unusual twist in medical science: demanding proof of
effectiveness of no treatment rather than of active intervention.
Although the no treatment stance has been viewed as radical, it is
actually quite conservative. The drug industry has to show both safety
and efficacy before commercial approval of its products, and, in
general, the burden of proof lies with those advocating treatment.
Health effects of dieting
Proponents of dietary treatment point to the health risks of obesity.
Amassing evidence that weight loss would be beneficial does not make
treatment any more effective. Therapies with modest success rates are
defensibly used when the prognosis for an untreated person is poor and
treatment poses no additional risks. But in the case of dietary
treatments for obesity neither of these assumptions is clearly met.
Success rates are not even modest, and the health risks associated with
untreated obesity remain controversial, largely because in societies in
which dieting is common the effects of high weight are confounded with
the effects of weight cycling.1,9 Dieting not only fails the criterion
of being without risk but has been implicated in increased morbidity
and mortality in several large studies.1,9,10 Dieting often has
negative effects on psychosocial functioning and can lead to eating
disorders such as the binge eating disorder and even bulimia nervosa.11
Finally, dietary treatments are costly, unpleasant, and, when they
fail, tend to damage self esteem.
Treat the patient not obesity
Of course obese patients should be treated for illnesses and injuries
like everyone else. They should be counselled to eat a healthy balanced
diet and to get appropriate amounts of exercise. They should be treated
for the emotional disorders they have and not, as is so often the case,
ones they do not have. They should be treated for eating disorders such
as binge eating, if they have them. Some must be helped to stop chronic
overeating caused by despair over repeated failure. Some will need help
in establishing "normal" eating patterns after decades of diets and
diet rebound. They should be helped to deal with the social and
emotional implications of remaining fat and to improve their body
image. One of the highest priorities should be to protect them from
blame for their condition and the enormous costs resulting from fat
prejudice.
Gotmaker et al recently put the costs of prejudice in terms that
everyone can understand: $6710 (pounds sterling 4470) a year in lost
earnings, as well as fewer years of education and a reduced chance of
marriage for American women in the top 5% of weight for height.12 Many
previous studies have documented discrimination in admission to
colleges, employment, promotion, access to housing, and attribution of
personality traits.11,13 In a commentary Stunkard and Sorensen
criticised the medical profession for being "among the chief offenders"
in the perpetuation of prejudice and issued a "call to action against
the stigmatisation of obesity."14
But how? Prejudice is revived daily in the routine interactions of
doctor and patient in which patients are offered dietary treatments and
fail to benefit from them. This ongoing failure demands a culprit:
either the treatment is flawed or the patient is flawed, failing to
comply with the appropriate remedy. As the more credible medical
profession is refusing to blame its prescriptions patients are left to
absorb the stigma of failure.
We should stop offering ineffective treatments aimed at weight loss.
Researchers who think they have invented a better mousetrap should test
it in controlled research before setting out their bait for the entire
population. Only by admitting that our treatments do not work - and
showing that we mean it by refraining from offering them - can we begin
to undo a century of recruiting fat people for failure.
***********
And start offering effective solutions like low carb diets.
The truth is timeless. In case anyone wants to make a big todo about
the date of this piece.
Twelve years and counting and we still have assholes pushing low fat
dieting.
TC
BMJ 1994;309:655-656 (10 September)
Education and debate
Controversies in Management: Dietary treatments for obesity are
ineffective
C S Wooley, D M Garner
University of Cincinnati, College of Medicine, Cincinnati, Ohio 45267,
USA Beck Institute for Cognitive Therapy and Research, Bala Cynwood,
Pennsylvania 19001, USA Correspondence to: Dr Wooley.
It is surprising that debate continues about the effectiveness of
dietary treatments for obesity. Perhaps this is partly related to
ambiguity in the term effectiveness. It is well known that most
treatments produce temporary weight loss. But it is equally well known
that 90% to 95% of those who lose weight regain it within several
years.1 This poor outcome has led to charges that traditional
treatments for obesity should be abandoned and countercharges that it
is irresponsible to withhold treatment for such a serious problem. The
failure of reducing diets to produce lasting improvement was recently
reiterated at a National Institutes of Health consensus conference,
which also warned about the adverse effects of treatment.2
The failure of fat people to achieve a goal they seem to want - and to
want almost above all else - must now be admitted for what it is: a
failure not of those people but of the methods of treatment that are
used. It is no longer a mystery why diets have such a poor long term
record of success. Indeed the failure of obese people to become or
remain thin by "normalising" their food intake follows logically from
studies on the heritability of obesity,3 the biology of weight
regulation,4 and the physiology of energy metabolism.5
Demand for treatment is not a justification
Yet many remain enthusiastic about treatment. It could be said that the
main evidence for the value of dieting is that health professionals
continue to prescribe it. Inertia feeds on itself, failure to change
coming to serve as a silent argument that no change is needed. However,
this only partially accounts for the resistance to change among those
treating obesity. Recent findings regarding the benefits of antibiotics
in treating ulcers and the comparative outcomes of procedures for
emergency cardiac care have been rapidly translated into medical
practice. In these cases doctors have only had to adjust what they do;
in the case of obesity treatment, however, there is no replacement
procedure. The question is whether to abandon treatment, putting many
specialists out of business, in the face of relentless popular demand.
Desperate consumers are willing to bear the burden of responsibility
for failure in exchange for continuing access to treatment. This
desperation is best illustrated by Ravitch and Brolin's observation
that patients who had had obesity surgery were unwilling to consider
reversal even when it was discussed in terms of saving their lives.6
As if to avert the central question by introducing more variables, the
debate has shifted from the universal mandate for one treatment, to the
matching of available treatments (from self directed programmes to
surgery) to individual, depending on level of obesity and factors such
as diet history.7 Notably, even for patients as little as 5% overweight
the option of withholding weight loss treatment does not appear on the
decision tree. Wadden has argued that the "no treatment" option "cannot
be universally endorsed until there are definitive research data."8
This is an unusual twist in medical science: demanding proof of
effectiveness of no treatment rather than of active intervention.
Although the no treatment stance has been viewed as radical, it is
actually quite conservative. The drug industry has to show both safety
and efficacy before commercial approval of its products, and, in
general, the burden of proof lies with those advocating treatment.
Health effects of dieting
Proponents of dietary treatment point to the health risks of obesity.
Amassing evidence that weight loss would be beneficial does not make
treatment any more effective. Therapies with modest success rates are
defensibly used when the prognosis for an untreated person is poor and
treatment poses no additional risks. But in the case of dietary
treatments for obesity neither of these assumptions is clearly met.
Success rates are not even modest, and the health risks associated with
untreated obesity remain controversial, largely because in societies in
which dieting is common the effects of high weight are confounded with
the effects of weight cycling.1,9 Dieting not only fails the criterion
of being without risk but has been implicated in increased morbidity
and mortality in several large studies.1,9,10 Dieting often has
negative effects on psychosocial functioning and can lead to eating
disorders such as the binge eating disorder and even bulimia nervosa.11
Finally, dietary treatments are costly, unpleasant, and, when they
fail, tend to damage self esteem.
Treat the patient not obesity
Of course obese patients should be treated for illnesses and injuries
like everyone else. They should be counselled to eat a healthy balanced
diet and to get appropriate amounts of exercise. They should be treated
for the emotional disorders they have and not, as is so often the case,
ones they do not have. They should be treated for eating disorders such
as binge eating, if they have them. Some must be helped to stop chronic
overeating caused by despair over repeated failure. Some will need help
in establishing "normal" eating patterns after decades of diets and
diet rebound. They should be helped to deal with the social and
emotional implications of remaining fat and to improve their body
image. One of the highest priorities should be to protect them from
blame for their condition and the enormous costs resulting from fat
prejudice.
Gotmaker et al recently put the costs of prejudice in terms that
everyone can understand: $6710 (pounds sterling 4470) a year in lost
earnings, as well as fewer years of education and a reduced chance of
marriage for American women in the top 5% of weight for height.12 Many
previous studies have documented discrimination in admission to
colleges, employment, promotion, access to housing, and attribution of
personality traits.11,13 In a commentary Stunkard and Sorensen
criticised the medical profession for being "among the chief offenders"
in the perpetuation of prejudice and issued a "call to action against
the stigmatisation of obesity."14
But how? Prejudice is revived daily in the routine interactions of
doctor and patient in which patients are offered dietary treatments and
fail to benefit from them. This ongoing failure demands a culprit:
either the treatment is flawed or the patient is flawed, failing to
comply with the appropriate remedy. As the more credible medical
profession is refusing to blame its prescriptions patients are left to
absorb the stigma of failure.
We should stop offering ineffective treatments aimed at weight loss.
Researchers who think they have invented a better mousetrap should test
it in controlled research before setting out their bait for the entire
population. Only by admitting that our treatments do not work - and
showing that we mean it by refraining from offering them - can we begin
to undo a century of recruiting fat people for failure.
***********
And start offering effective solutions like low carb diets.
The truth is timeless. In case anyone wants to make a big todo about
the date of this piece.
Twelve years and counting and we still have assholes pushing low fat
dieting.
TC
