Opinion

I thought exercise and diet would help my patient tackle obesity – I had to think again


Hester Wilson


26/08/2019 3:09:57 PM

Dr Hester Wilson is reconsidering her long-term approach to treating obesity.

Woman exercising
For Dr Hester Wilson’s patient, exercise simply wasn’t enough. (Image: World Obesity)

My patient, Jo, has been obese for as long as she can remember.
 
In our consultations, she would talk of life as an obese teenager, of the full quota of shame she experienced, both from her own loathing of her body and that given to her by others.
 
It has not stopped her from living, however. Jo has been successful in her career, had a family, and has many close friendships. But obesity is something that lingers in the background, always there.  
 
Jo has always worked at being fit – she has long been worried about her health – and over the years we had many discussions about her weight and ways to change the situation.
 
My focus was always on using long-term goals to slowly reduce weight, with a combination of exercise and diet. 
 
A few years back, Jo attended an intensive ‘fat camp’, after which she managed to lose a drastic 70 kg – only to put it back on over the following months.
 
This came as a real blow.
 
Jo then chose to go through bariatric surgery. While we had talked about this option, she had always told me it was a last resort because it felt to her like a failure of her self-control. I had never pushed it, and instead placed my faith in diet and exercise.
 
But after the surgery, I saw the change. Jo shed weight fast and has maintained her new, much lower weight. Her health has improved significantly. 
 
When she came to me recently, I asked Jo about how she now saw her lifelong struggle. Her sense was that the ‘fat camp’ was the turning point, while the surgery was adjunct.
 
I couldn’t help but wonder if it was, in fact, both.
 
Jo had been shaped irrevocably by the stigma that still persists around obesity. I had been working with Jo for such a long time before we found an answer that worked for her.
 
I have recently been seeing a number of obese adolescents. Hearing their stories of stigma and self-shame made me think of Jo, and I wondered why bariatric surgery was so hard to obtain for teenagers.
 
I wondered at my own prejudice and why my focus was diet and exercise when, given the links between obesity and health, the stakes are so high. And when, arguably, adolescents have the most to gain from acting early.
 
Should I have pushed earlier to encourage Jo to have the surgery? Was it my prejudice that kept me working the same way for so long? Deep down, had I bought into the idea that obesity had to be changed through willpower?
 
And, given how much bariatric surgery had helped Jo, should I push to find options for obese adolescents to have surgery now? Could I save them decades of struggle?
 
I don’t know the answers to these questions. I’m sure there’s good information about bariatric surgery outcomes that could help me find the way through.
 
But, right now, I’m more interested in the experiences of the people I see and helping them to find the right answers. And I’m interested in always questioning myself and my approach, and in learning from my patients. In this area, Jo has been my greatest teacher. 
 
As Jo recently concluded, to get her to the point where she achieved the change, it took the camp, the rebound weight loss, and finally the surgery. She believes she has made the right choices.
 
She just wishes she been able to make them earlier in life.



bariatric surgery obesity stigma



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John Dixon   27/08/2019 6:43:39 AM

Unfortunately your experience is normal, physiological, and expected. Obesity is a progressive relapsing heritable neuro-behavioral disorder. It’s a serious condition that is very well understood. GPS and their College in particular are content to let myth reign. John


Muhammad   27/08/2019 7:08:14 AM

Should you have “Pushed” And “encouraged” her for bariatric surgery?
A doctors job is not to “push” the patients into anything. It is also not to ‘convince’ them to agree with the doctor. A doctors job is to present the pros and cons and to present it in a langauage they can understand and can reflect imupon these issues in a meaningful manner.
Let us suppose that doctor ‘A’ pushed the patient wnd patient had surgery- and then they died of complications. How about they developed some long term morbidity?
OR WORSE:
They put their weight back on?
All of the above - are real complications and I have seen these happen in my clinical prqcruce.
More than once, patients have said something to the effect “if I knew I would end up putting this much weight back on, I would not have has this surgery”. (And this weight they out back on was much less than their original starting weight, but it was still a lot of weight). And doctor ‘A’ would get blamed if he/she had pushed it.


Dale van der Mescht   27/08/2019 7:12:31 AM

I refer heaps of patient for gastric sleeve surgery. If they have tried more Han 3 diets and really stick to them but still battle with “yo-yoing” then I don’t really believe there is any other way to improve their health. It’s not a cop out or a shirt cut or the easy way... it’s the solution.m to a very difficult problem


Muhammad   27/08/2019 7:16:33 AM

I would say this:
Dont be so harsh on yourself- for you did the right thing- you did not make the situatiin worse. Be kind and generous unto yourself - for you deserve no less than what you offer to others . Make no haste, and do not judge your self too soon- for in the end we are all humans and none of us is perfect. Do not presume , for you know not, what could have gone wrong , had you pushed her for surgery sooner. You have done very well- for she is still alive and doing well. Take love and pride in what you have already acheived- and I can tell you that you have achieved a lot.
So be kind to yourself - please? :-)

Another thought:
It sounds that it wasnt too long ago that this patient had her surgery. Wait for a year or two. And you will likely be happy that you didnt push her or encourage her to get surgery sooner.


Dr Annette Hackett   27/08/2019 7:45:17 AM

Doctors can play an enormous role in obesity and health. And I would prefer to see them do this by reducing shame. Fat shaming, and the mental health issues that go along with that, cause an enormous toll on anyone who sees their body as not fitting the 'norm' as sold to us the media. Shame will often then lead to behaviours which reduce health (eating to stuff down feelings, alcohol and other drug use, self harm etc.). By seeing people as people first and always, whatever size they are, we can let people know that we will care for them however they are. This is what gender diverse people expect, those who are not neurotypical (on the autism spectrum), those from a wide variety of ethnic backgrounds etc expect - we treat all those who come to us with respect. By promoting weight loss instead of health, we can inadvertently shame those who come to us for support. 'Health at every size' is a possibility. We need to be the first to stop the shame.


Dr Peter J Strickland   27/08/2019 1:42:11 PM

The case stated here by Hester Wilson shows that this patient DID have the capacity to lose 70 kg, but did not persist with the same regime she had been taught and successful with in the first place. Having bariatric surgery is NOT a natural procedure to recommend, and especially with teenagers. -- it should be a rare procedure to recommend. I would only recommend it for patients with other serious pathology incl. intractable NIDDM and morbid obesity. The surgeons are charging a fortune for what has become an easy procedure for them, and obesity in children should be a matter of diet and daily hard aerobic exercise -- many of them now lack motivation to help themselves and improve their mental and physical health by such discipline -- it is a shame!.


Kristin Boyle   27/08/2019 2:15:07 PM

Dr Strickland, with respect I find your comment very unhelpful, and it shows a real lack of understanding of overweight and obesity. It's well known that keeping off weight long term that is the challenge. Trying hypoventilating. Can you keep it up for a minute? 2 minutes? An hour? Good work, but it takes constant concentration and effort, and eventually you will fail, and go back to breathing normally. This is a good analogy to long term calorie restriction. Evidence shows that the percentage of people who lose a significant amount of weight, then maintain that weight loss for > than 5 years, is in the low single digits, and of those who are able to maintain that weight loss, a good proportion meet the criteria for a clinical eating disorder. Have you noticed there has never been a Biggest Loser reunion show? Food and weight are extraordinary complex, and blaming individual children (or adults) for their lack of motivation and discipline will never be part of the solution.


Rosalie fuzes   27/08/2019 4:08:32 PM

I firmly believe that the brain and or genetics determine our weight and we can control perhaps 10% with diet and exercise ( bit like cholesterol)
There was a very interesting experiment done in UK where they studied healthy underweight people.
For a month they were fed a high calorie diet to gain 5kg.
They all complained of feeling uncomfortable.

When they were allowed their normal diet they automatically reduced their calories till they regained their normal weight


Dr Natalie Bassat   27/08/2019 6:27:42 PM

I applaud Annette Hackett and Kristin Boyle. Doctors should first do no harm and need to stop fat shaming patients for whom weight loss is near impossible. Doctors continue to push diets despite all the clinical evidence that 95% of patients will not succeed in maintaining weight loss over a 5 year period. This is not because of a lack of self discipline but because of the complex physiological psychological cultural and socioeconomic factors at play that make it so difficult. I counsel many for whom bariatric surgery has been unsuccessful with significant weight regain (they then feel even more of a failure) and many who have had terrible complications that make life very difficult albeit in a thinner body. Diets do real harm especially in teenagers for whom they are the prime catalyst for eating disorders and are associated with increased wgt gain. Doctors should show more compassion and help reduce weight stigma. The ‘Health at every size’ model is a step forward.


Dr Nicola Behne-Smith   27/08/2019 7:23:53 PM

I think it is almost all mentality. The formula is what goes in and what goes out(exercise). The latter always works when able when the diet is limited. The problems arise when both are not adhered to or there is an impediment to exercise such as mobility issues.
Bariatric surgery is a a quick fix and for some that gives that impetus, just like for some the success at weight loss through exercise gives impetus to keep it off , but for a select few , in the long run they bounce back as the mentality issue of eating too much is not fixed. I have already seen this in 3 patients and two friends. So horses for courses, whatever it takes as obesity kills . Bariatric surgery should be free and more easily available to give people a chance at success before the long term killers set in , if they have failed in the exercise and diet. But let them beware it will come back if they slip to bad habits again......

how do we fix the mentality is how we fix obesity in the very long term.


Paul Triggs   27/08/2019 7:56:20 PM

The science is diet works. For a bit. Then you go back to your set point weight and guard it like a dog. Do a literature search and you can read for hours. I agree with John Dixon, the college is living in the 70s


Graham Lovell   27/08/2019 10:34:47 PM

Having seen the obesity /diabetes epidemic evolve in Australia via GP perspective over 35 years . I have seen so many patients trying so hard torturing themselves while constantly hungry to follow what now has been proven to be pointless calorie restriction diets that inevitably aren’t sustainable .
I understand we have enough people on the public bariatric surgery lists in SA that realistically you’re looking at over 10 years.
Is there a realistic solution for this dramatically life impairing and shortening problem??
NO-well not until we treat access to high carb, high sugar foods as the issue that has chronologically timed with the epidemic, and scientifically
has been shown to trap people by rebound hunger.
I didn’t believe it until I was seeing those patients who escaped the WRONG Pyramid of food types easily maintaining 15 to over 35% loss of total body weight, without calorie counting and NOT HUNGRY!
Clearly Older,obesity complication effected patients engage easier


Daniel Ewald   28/08/2019 3:23:42 PM

Clearly a hot topic! Good pick Hester.
- which is good compared to therapeutic nihilism.
There have been a range of proposed solutions mostly focused on one or two favorite aspects of the obesity epidemic.
I think obesity may be the result of a number of underlying issues including: mental health, birth weight, supportive and safe physical environment, diet, medications, old emotional or physical trauma, exercise, cognitive barriers (myths), food tax policy, transport policy and probably more.
We need to work on all these fronts, bit like we do for smoking , but even more complicated.


David Lim   31/08/2019 9:00:56 AM

Could it be we got the energy in/energy out model wrong? This implies the system is passive, simply a recipient of energy .. but our bodies are homeostatic systems .. and we just defend against a hypocaloric approach to weight loss. Shall we be courageous enough as a scientific community to ask the hard questions .. after all that’s what we’re trained to do as doctors .. did we get this wrong? Do we dare tackle other models of weight gain/obesity/diabesity and ask if the hyperinsulinaemia/weight gain model merits more discussion ... and if does, then the lower carb, no sugar approach to weight loss. If we use a VLCD diet that excludes real food, then a nutritionally balanced low carb approach merits our attention too.


Susan Swanston   31/08/2019 11:52:59 AM

Bariatric surgery is no magic wand and when you see one of your patients spend 10 weeks in ICU after a near fatal leak, it changes your perspective. Patients can lose weight very successfully on a low carb/keto diet which combats their underlying insulin and leptin resistance. Unfortunately for some, their mindset is too stuck to embrace change and they get little or no support from the medical profession. There are a small number of patients in whom surgery does provide them with a kick start, but they still need that support post operatively. The calories in/out model is flawed and we need to stop making our patients' lives more miserable by perpetuating the myth. Let them eat fat and thrive!


Gregory Williams   1/09/2019 6:24:44 AM

Is it complicated? No. . Difficult? It depends . I am from a family of overweight people. When we were all young we were all active and slim. I am the eldest. A few years ago I was putting on weight 10 kHz despite being quite active. I started having an apple for lunch every working day and in a year I had lost 10 kgs and that weight loss was maintained. Easy lower calorie routine is KEY.


John Barclay   22/09/2019 6:34:10 PM

If anyone wants to know why we have an obesity / T2DM pandemic, read Escape the Diet Trap by Dr John Briffa - it contains all anyone needs to know. Lots of similar info on the net. Go on to You Tube and listen to anything Jason Fung says. And Robert Lustig. And Zoe Harcombe. And Dr James Unwin. Its all about types of foods we eat ( and how often ) and the hormonal response of the body to the foods ingested - and how that causes fat accumulation even on a low calorie diet. Calorie restriction for weight loss is usually counter productive. Jason Fung explains why this is very well. Quite right it's not " eat less move more". Vast majority could turn round their metabolic syndrome etc without resorting to bariatric surgery. I never used to believe oveweight people who said they are very little but having been enlightened by the resources I mentioned, it all makes perfect sense now.


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