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Revised draft Clinical Practice Guidelines for the Management of Overweight and Obesity in Adults, Children and Adolescents

ID: 
6
Personal Details
First Name: 
Jennifer
Last Name: 
Lee
Additional Information
In regard to your comments, do you have a Conflict of Interest to disclose?: 
No
Specific questions
Question 2: What would help you implement these recommendations into practice?: 

I'm responding as a member of the public - an academic.

Specific comments
Comments: 
Summary

Please see above - I have grouped all my comments together. I don't really have time to separate them all out in this fashion.

General comments
Comments: 

I am concerned about the assumptions made in the document, and the harm that those assumptions do to 'obese' patients. While a document such as this doesn't require the heavy referencing of an academic paper, it should still acknowledge the available research. For instance, the draft Obesity Guidelines state, 'Excess weight results from prolonged energy imbalance, where
energy intake is greater than energy expenditure, with the excess energy stored as body fat.' Well, sometimes it does. But there is a lot of research that shows that set-points are raised through chronic dieting and the earlier a child goes on a diet, and the longer the dieting continues, the more the body goes into starvation mode, and the fatter you get over time. Why isn't this research being acknowledged? Much of this research is outlined in Linda Bacon and Lucy Aphramor's paper 'Weight Science: Evaluating the Evidence for a Paradigm Shift', free and available at this link <http://www.nutritionj.com/content/10/1/9/> (and Linda Bacon's book, Health at Every Size).

This statement is said to be the intent of the guidelines: 'An underlying principle is that care is centred on the needs of the affected individual,
that it is culturally appropriate, non-directive and non-judgmental, and that it enables people to participate in informed decision-making at all stages.' If you want to empower the 'overweight' and 'obese' (I think patients should be asked which terminology they prefer, first of all - many of us prefer 'fat' as a descriptor), then take the focus completely off weight. Weight is an outcome - not a behaviour. A behaviour change is to eat well, focus on nutrition, and do plenty of exercise - that may or may not result in weight loss. As you admit in the document, weight is easier to put on and harder to get off, therefore, once you're fat, why not focus entirely on improving health outcomes, not weight loss. It is disempowering to make people focus on an outcome that they may or may not be able to achieve. However, if you take the focus off weight, you then need to ask all patients about their health - not all thin people eat well and do exercise, and they slip under the radar. A friend of mine said recently, 'Oh, so-and-so eats a block of chocolate a day, or a packet of tim-tams,' I answered, 'Doesn't he have a heart condition,' my friend answered, 'Yes, but he has a fast metabolism - he's so skinny,' and I responded, 'that doesn't mean he's healthy.' There seems to be this mental block - that thin on the outside equals healthy to most people. This is a problem, and it's an underlying problem with the methodology of your approach.

'At present, there is no single effective intervention' - intervention to lose weight, or intervention to improve health? I joined the gym and my blood pressure went from borderline high to normal, but I actually put on 2 kilograms in the process (who knows if it's muscle or fat). Was that an unsuccessful intervention or a successful one? The success of an intervention should be measured by cholesterol, blood pressure, blood sugar, triglycerides, etc - not weight loss. Those other aspects are what lead to illness, not the weight itself - in some fat people, those numbers are fine, in others they're not, and in some thin people, they're not. That's why the weight focus needs to be rethought. The medical governing bodies need to rethink this - think back to some of the medical beliefs that have caused damage in the past. Margaret Heffernan writes about wilful blindness in 'Why we ignore the obvious at our peril', and she gives this as an example:

'In 1956, the Oxford-based epidemiologist Alice Stewart demonstrated, with startling data, that the chances of childhood cancer were vastly increased by X-raying pregnant mothers. At the time, these cancers were killing one child every week, yet it took 25 years before the practice was abandoned by the British and American medical establishments. Stewart’s data flew in the face of current epidemiological theory – “threshold theory”, which maintained that,
while a large dose of anything could be dangerous, there was always a point, or threshold, beyond which it was bound to be safe. Her research indicated that there was no safe level of radiation for foetuses. Stewart was fiercely opposed by Britain’s foremost epidemiologist of the time, Richard Doll, who was famed for identifying the link between smoking and cancer. Not until 1997 did he quietly retire the threshold theory with the most modest of mea culpas.
Big ideas can create tunnel vision, blinding the believer to disconfirming data. This cognitive dissonance is resolved in favour of the faith.'

Why do medical establishments ignore scientific evidence?

I think this is a start: 'Goals should focus on behaviour change and improved health rather than on weight loss alone. For most overweight and obese adults, weight loss of 5% of initial body weight is achievable and will reduce health risks, including lowering blood pressure and reducing the risk of or delaying progression of type 2 diabetes.' However, I argue that, for a non-judgmental approach, you should recommend focusing only on health and the blood tests/blood pressure, not on weight. Yes, 5% of weight loss is correlated with reduced health risks, but is it the 5% weight loss or the healthier focus to their life that makes the difference? Why all this focus on 'obesity time bombs', 'obesity costs this much', if only 5-10% of weight loss is achievable. You can't use shame to make us lose weight - mental health is part of the health equation too. If someone at 140 kilograms can only reaslistically achieve weight loss of 7-14 kilograms, they'll still be obese, they'll still be affected by all the shaming messages - which is one reason why a health focus, not a weight focus is important. We have a self-esteem and body image epidemic, and it's worse than the 'obesity epidemic' - women of all sizes, even 'normal' weight, hate their fat, hate their bodies, and self-hatred is very detrimental to mental health. This is a complex issue.

'Bariatric surgery is the most effective intervention for severe obesity, with or without comorbidities.' No it's not. If you read the data on mortality rates and side-effects of bariatric surgery, it's rarely, if ever, a good choice. The Director of the University of Melbourne Obesity Consortium, Professor Joe Proietto, rightly argues that diet and exercise do not often reduce weight in the long term. But he also argues that weight loss surgery is the answer, though he doesn’t disclose the horrific side effects. The 2005 study, ‘Early Mortality Among Medicare Beneficiaries Undergoing Bariatric Surgical Procedures’ by David Flum and five others, in the Journal of the American Medical Association, found that 4.6 percent of people who underwent the operation died within a year. Complications of weight loss surgery are outlined in Linda Bacon’s Health at Every Size: anemia, arthritis, body secretions, cancer, chest pain and erosion of teeth enamel from vomiting, depression, early onset of diabetes, hair loss, infertility, malnutrition and … wait for it… weight regain.

Measuring a BMI - who does that help? To put us in a medical category - the whole thing is dehumanising. BMIs aren't always accurate anyway. Again, putting us in a category and then saying - well, lose 5% of your weight, and keep it off, and then you'll... be in the same category. Not overly helpful, except that you get to classify us as being in the 'wrong' category. Mental health is a factor here - we arenot just scientific robots who can be measured, and weighed and told 'your BMI is 40, therefore you're obese'.

Your Recommendation 11: 45-60minutes, five times a week. Again, you're setting up unrealistic expectations here, especially if you're recommending to anyone who isn't used to intensive exercise. I told a medical professional I'd joined a gym and was going 2-3 times a week and I walked the dog 3-4 times a week (my partner did it other days). Her response was 'you need to go to the gym five times a week or walk without your dog - they stop and sniff, and your heart rate goes down'. Really? That's what she had to say in the way of encouraging words to me? Should I feel chastised and defeated? I did feel that way. I felt terrible. Do thin people get that response too? Do they even get asked if they do exercise, or is it assumed they do? I'm an academic, but I just want to say it the way it is: I felt shithouse for a week after seeing that medical professional, and I had to force myself to walk the dog - I felt like crawling into a ball. Then, after a week, I got really angry at her, and started thinking 'what do you think of this, (insert insult here) - I'm eating crumbed fish instead of steamed fish. What a sin! Lucky you're not here to see me.'

Recommendation 12: Consider the use of orlistat... That only results in 5% of weight loss, and has side-effects, and once the medication is stopped, weight gain often results. Why recommend that? When are you going to see that Health At Every Size is a viable option, and often results in a 'side effect' of some weight loss anyway. But even if it doesn't, surely healthy eating and exercise - and let's not forget stress, sleep, and mental health - all factors that are being neglected at the expense of the 'war on obesity' - are the true goals. Although, I'd like to point out here that ill-health should not be a reason to judge someone - even the fattest person in the world. We all deserve respect, dignity and care.

Recommendation 19: Plan weight management programs for children and adolescents that involve frequent contact with health professionals. - I think this is the worst thing you could do - make a child feel measured, weighed, inadequate and judged. Unless the child presents with health problems, don't intervene. Do blood tests if you have doubts. Talk about healthy eating to all families - not just the ones with fat kids. Kids go to extremes too - developing damaging eating disorders to lose weight.

In Australia, there is an absence of published quantitative research on the link between obesity messages and unhealthy eating behaviours in children. Nonetheless, the Royal Children’s Hospital chair of adolescent health, Dr Susan Sawyer, says, ‘These adolescents have anorexia nervosa in terms of how unwell they are, the distorted body image and the amount of weight loss, but they are at normal weight. This is very new’. (Brigid O’Connell, ‘Anti-obesity panic blamed for new eating disorder’, February 11, 2012 <http://www.news.com.au/national/anti-obesity-panic-blamed-for-new-eating-disorder/story-e6frfkvr-1226268696307> accessed 24 March 2012.) These medical professionals are at the front line and we should listen when they say new eating disorders are resulting from anti-obesity messages. Yet, while they are encouraging less extreme anti-obesity campaigns, they are still advocating surveillance and measurement of weight and are unwilling to consider Health at Every Size (HAES) principles.

22: Postpubertal adolescents with a BMI >40 kg/m2 (or >35 kg/m2 with obesity-related complications) may be considered for laparoscopic adjustable gastric banding via specialist paediatric centres if other interventions have been unsuccessful in producing weight loss.
 
My response - I hope, at a minimum, these adolescents are first sent to a psychologist or psychiatrist, to assist them with making such a decision about their own bodies. I disagree that an under-18 year old should have this procedure. They are still developing in many ways, and they don't have the autonomy over their own lives that adults have - to even control their lifestyles completely.
 
You talk about the health problems related to excess weight, but you make the leap that excess weight always leads to health problems - this is an error in cause and effect, and a huge error for what is supposed to be based on scientific evidence. It is an error that is damaging so many people because so many assumptions are being made about the lifestyle you live if you are fat.
 
You state, 'Intensive interventions include very low energy diets, weight loss medications and bariatric surgery' - none of these maintain long term weight loss in most people. People can't maintain very low energy diets forever, without developing an eating disorder - that's why the weight goes back on. 
 
'People are likely to feel safer in healthcare interactions when mental, social, spiritual and cultural as well as physical aspects are considered.' How does this report assist medical professionals to ensure that happens, with its recommendations to measure BMI, and talk about weight loss at all costs - even at the cost of health, I think. I do not feel safe with people judging, weighing and measuring me, and telling me my body is wrong. I can walk, swim, ride a bike, have sex, do gardening - my body does what I need it to do. I'm sick of these constant messages to  'change' - especially when even your report admits that this desired 'change' is 5-10% of weight loss, for me 6-12 kilograms! I won't suddenly become thin. What if I do lost 10 kilograms, then go to a different doctor, are they going to measure my BMI, weigh me, tell me to lose more weight? Should I yo-yo diet - when the effects of weight cycling are emerging as damaging? My tone is getting frustrated because it seems so obvious to me that you're on the wrong track with the weight focus. In 10 or 20 years, this will be another 'well intentioned' medical bungle. I'm sorry, but 'first do no harm' includes 'first do no harm with your good, but close-minded, intentions'.
 
'The same physiological mechanisms then seek to maintain energy balance at the higher weight, and
will defend against weight loss by increasing appetite if there is an energy deficit.' - in other words, once you're fat, you're probably going to stay fat. Also note, that restrictive diets then lead to binge eating and larger consumption of food - you could argue that restrictive diets are a primary problem. The body responds to those by eating until all the weight is put on, plus more. Encourgaging restrictive diets will not result in long-term weight loss. That will result in long-term weight gain.
 
'Longer working hours and both parents or partners being involved in the workforce
leave less time
for food preparation and family recreation and physical activity. Loss of regular meal patterns and
family meals leads to more snacking and higher kilojoule intake.
• Disrupted sleep or too long or short periods of sleep can disturb metabolic processes and interfere
with systems for appetite control and has been associated with weight gain, especially in shift
workers and children.' Yes - longer working hours and the resultant stress, and working late, have been identified as health problems for me. Yes medical professionals assume my problem is with my diet. That's because of the overwhelming focus on 'fat people eat too much' and other stereotypes about fat people.
 
4.3.4 Readiness to change: You need to distinguish the difference between being ready to change, health being a priority for someone, and forcing the link to weight loss. Health is a priority for me, which is why I focus on health and not weight loss. If I focused on weight loss, I would eat inadequate amounts of food, as my 'set point' weight would require me to, in order to be thinner. You are making links which force GPs to label someone 'non-compliant', if they are fat but don't want to focus on weight loss. Also, you are creating a link that doesn't need to be there.
 

 'A large investigation into the effect of obesity on mortality (n=900,000) found that people who were moderately obese (BMI 30–35 kg/m2) died 2–4 years earlier than those with an ideal weight. A BMI of 40–45 kg/m2 reduced life expectancy by 8–10 years, comparable with the effects of lifelong smoking
(PSC 2009).' Have they proven that this is due to being fat, not due to weight cycling? I'm not trying to say that there's no link between weight and health, but I am pointing out where assumptions are being made. What about the research that shows 'overweight' is the safest category to be in when you're over the age of 55.

6.2.1 How long does the weight loss associated with low energy diets last? If it's not longer than five years, the weight cycling is damaging. And it doesn't last once people come off those diets.

 

'Eventual weight regain after bariatric surgery occurs regardless of the bariatric surgical type. Achieving
long-term weight loss therefore requires weight management strategies to be continued after bariatric
surgery has been performed. As well, resolution of comorbidities may not be sustained in the longer
term and continuing monitoring of these is required.' Mmmm - not exactly effective, is it? Is it worth the side effects. You are not presenting any long-term weight loss strategy in this document. In fact, beyond 5-10% weight loss with lifestyle change, there's no successful weight loss stragegy. So - stop focusing on it, and try focusing on health instead! In everyone - not just the fat.

To conclude - what are you going to do to reduce stigma and prejudice directed at 'overweight' and 'obese' people? All this focus on weight is damaging, in particular to women, who are already faced with anorexic models in magazines as their 'role models'. You can't expect someone who is 120 kilograms to lost more than 6-12 kilograms in the long term. What are you going to suggest, to stop doctors assuming that, when that person enters their office at their weight of, say, 110 kilograms, that they  need to lose weight? Or what if that person stays at 120  kilograms but is in perfect health? Why should they go on a reduced calorie intake? To being weight cycling again? And what if that person is at 120 kilograms and is in poor health, with high blood pressure and high blood sugar? That walking helps reduce blood pressure - OR lose weight at any cost? I have been very critical. I was 'identified' as a chubby kid, put on my first diet at 8 years old, and dieted, followed by bingeing and weight regain for 20 years. The only thing the 'lose weight' message did was cause more and more weight gain. So I'm not 'non-compliant' when I say I will not aim to lose weight anymore - because I am aiming for healthy eating and exercise. These guidelines might be backed up by a literature review, but that literature review is following a very particular methodology and sits within a certain paradigm. This desperate effort to get the message out about weight loss, with very little evidence of effective practice needs to stop! It is doing harm in the way of increasing fat stigma, and it is not an effective health message.

 

 

 

 

 

Page reviewed: 6 September, 2012