The Blog

New Year - Same Old Nonsense About Obesity

No intervention for obesity has been proven to produce clinically significant and sustainable weight loss in the medium- to long-term. Not diet, not exercise, not behavioural interventions, not even bariatric surgery.

Welcome to a new year and a new onslaught of anti-obesity messages from the establishment. To get us off to a good start, the Royal College of Physicians have just released their report 'Action on obesity: Comprehensive care for all'. The report mainly focused on the mish-mash of service provisions for obese individuals across the UK - something that is hard to argue with. Whether it matters at all is another matter entirely.

The amount of spin in this so-called professional document is making me so dizzy, I almost don't know where to begin, but I'll just concentrate on some of the most wildly misleading misrepresentations.

The report recommends "commissioning weight management services which have proven effectiveness." Good luck with that. No intervention for obesity has been proven to produce clinically significant and sustainable weight loss in the medium- to long-term. Not diet, not exercise, not behavioural interventions, not even bariatric surgery. Evidence is mounting that weight regain following bariatric surgery is common, and even the much-touted benefits in terms of diabetes 'remission' show high rates of relapse within five years. The health costs of the surgery itself, the complications, the malnutrition, the increased risk of severe depression, do not disappear that readily. Oh and death. That's pretty permanent too.

As for non-surgical interventions, while most weight loss interventions work in the short-term, every single study that looks at the longer term effects - over two to five years, say, show that the vast majority end up back where they started, or heavier - possibly as a result of the effect of the 'treatment' on the body itself. A very thorough review of longer-term randomised controlled trials of weight loss interventions first of all only managed to find 12 studies with over 18 months follow-up, most of them with serious quality issues in terms of data reporting (like ignoring all the people who regained weight), and even so, the longer the follow up, the greater the likelihood of returning right back to where they started.

In fact, even compared with no treatment at all, the differences after two years ranged from nothing to around four or five pounds. As a colleague of mine is wont to say, "I could lose five pounds in two years just by exfoliating regularly." Given a large enough study, five pounds may work out to be statistically significant, but the impact on health is likely to be practically nil. And if you include the damaging effects of dieting itself... Yet this is the study that is cited by the Royal College of Physicians, who are somewhat selective in their interpretation and reporting of the findings! Oh well, never mind, say the experts, they can just try again. But repeated weight loss attempts are not benign. Weight cycling, or yo-yo dieting, almost doubles the risk of all-cause mortality, including death from heart disease, compared with just staying fat in the first place.

Moving on. The Royal College of Physicians also cite numbers supposedly proving the burgeoning cost of obesity to the NHS. Although these numbers don't actually come from the RCP itself, they are the reason that significant intervention is deemed necessary, so let's have a closer look.

First, it is worth noting that these numbers include the enormous costs of treating people who aren't actually sick, based simply on their size. The common refrain is 'well, you may not be sick now, but you're going to get very sick very soon unless you lose weight.' There is absolutely no evidence for this. In contrast, there is increasing evidence that a significant proportion of obese individuals are at no increased risk of cardiovascular complications at all. And a good chunk of 'normal weight' individuals are. Thin people get diabetes too. And heart disease. And high blood pressure. Nobody is putting them on preventive statins.

Given the absolutely appalling track record of weight loss interventions, doctors jumped on the chance of prescribing newly available medications. Data from 2011 show nearly one million prescriptions for orlistat, at a cost to the NHS of £30 million. Side effects of orlistat include the pleasant experience of 'fecal incontinence.' Two other drugs previously prescribed in the UK, rimonabant and sibutramine, have since been withdrawn following concerns about side effects including severe depression, suicidality, increases in blood pressure, heart attacks and stroke, and a range of less severe but fairly incapacitating problems. Most recently, concerns have been raised about a possible connection between orlistat and liver toxicity and kidney damage. More costs of 'treating obesity' that we can blame on the human guinea pigs who are suffering the consequences of medically induced ill health.

And let's not forget bariatric surgery. NICE guidelines recommend weight loss surgery for individuals with a BMI of 40 or more, whether or not they have any other medical complications. Data from 2011 indicate a 30-fold increase in these procedures in the last decade. And it's not just the cost of the surgery itself. Add in the cost of dietetics support for the people who can no longer absorb sufficient nutrients to maintain health. Add in the cost of follow-up procedures to treat complications of the surgery. Add in the cost of treating complications from the increasing number of operations carried out privately. All costs of treating obesity.

And then there's the cost that nobody is talking about. The levels of prejudice against fat people are just shocking. And it's not just Joe Bloggs in the street. Our doctors and nurses think fat people are lazy, greedy, disgusting, and they'd rather not treat us at all. Everywhere you look fat people are dehumanised, made the butt of jokes, or the villain in all of society's ills. Bullying of fat people is one of the last bastions of legitimate bigotry. They suffer at school, at work, and yes, in health care. The effects of stigma and prejudice on the human body are well proven and not good. As well as causing significant increases in mental health problems like depression and eating disorders - another cost of obesity - the biochemical changes associated with this kind of stress are strongly related to increased risk of diabetes, hypertension, heart disease and so on - all the illnesses typically associated with obesity itself. Interestingly, in cultures where being fat is considered the ideal, the connection between weight and health is much weaker than in countries where fat is demonised.

This problem is brought into stark relief by the media coverage of the Royal College of Physicians report. Almost every story included stigmatising pictures of extremely obese people, spilling out of their clothes and usually represented as decapitated torsos - a phenomenon known as the 'headless fatty'. There was a joke doing the rounds on the internet a while back about how the obesity epidemic was putting hat manufacturers out of business - all these fat people with no heads - they just didn't need headgear anymore. But this is gallows humour. This representation of fat people is dehumanising and stigmatising and only worsens an already hostile environment for people who do not conform to modern-day cultural ideals.

In addition, the headlines of all of these stories revolved around the massive costs of obesity to society. As noted above, these are likely hugely over-inflated by unnecessary medical treatments and the cost of treating the after effects of the war on obesity itself. Further, this wasn't even a conclusion of the report itself - they're just numbers recycled from old surveys. And something else the media didn't cover was the funding many of the authors of the report received from companies peddling weight loss diets and pharmaceutical companies making weight loss pills and gastric bands.

But perhaps most importantly of all, it is far from certain whether all of this 'concern' is even necessary. Whilst there is undoubtedly a connection between increased weight and ill health, this does not imply a causal relationship. In fact, once you start taking account of factors such as fitness levels, socioeconomic status, and dieting history, the relationship all but disappears. And it has been conclusively shown that if you adopt healthy habits - five or more fruit and veg a day, moderate exercise, not smoking, and drinking only in moderation, your long-term health risks are absolutely no worse than a thin person who does the same, and they're a damn sight better than for people who don't live like this, whatever their weight. Where people go wrong, is that they think these kinds of healthy changes will make you thin. This isn't necessarily true if you're just not built like that. But they will make you healthier. And that is what should matter. Let's not make 2013 another year of scaremongering and fat blaming, but concentrate our efforts on ensuring equitable access to healthy environments and decent healthcare for all.