Healthcare's Weight Loss Best Case Scenario Problem Part 1 - The Basics

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When it comes to recommending weight loss, healthcare has always had what I call a Best Case Scenario Problem. I think the best way for patients to protect ourselves from this is to understand it so that we can spot it when it’s happening so in Part 1 I’ll examine how this works (in the past and currently) around behavior-based interventions and then in part 2 we’ll look at how GLP-1s are driving an increase in this problem and creating even more harm and what we can do if this problem happens to us.

Since the beginning of research into weight loss methods, the research has shown that the vast majority of weight loss attempts will result in weight cycling. That is, people will lose weight short term and gain it back long-term.

Many providers have simply refused to acknowledge this statistical and practical reality (and many still do.) Even providers who knew/know this still regularly recommend weight loss to higher-weight patients based not on what decades of evidence show is the most likely outcome, but based on their hope that every single one of their higher-weight patient will have (what they consider to be) the best case scenario outcome. (And I say what they consider to be because this belief in what is “best” arises from the weight-centric paradigm and is not shared by the weight-inclusive paradigm.)

Whether we are talking about weight loss or any other prescription/recommendation, when healthcare providers are giving patients a rosy picture based on a highly unlikely “best case scenario” it is a disaster both statistically and from an ethical informed consent perspective.

I’ve written before about how this is, essentially, lottery logic but in this case it is like your doctor is prescribing playing the lottery. It is especially concerning since weight cycling is not benign and, in fact, has been independently linked to significant harm (much of which is the same harm that gets blamed on existing in a higher-weight body and for which weight loss is recommended as a treatment, which is also why I so often feel like banging my head against my desk but anyway back to this article…)

In my experience these providers are not typically thinking, or at least speaking, about these weight loss recommendations as a highly unrealistic hope for the best case scenario for everyone. Instead, they use one or more justifications that are, scientifically and/or statistically, on a spectrum from problematic to disastrous.

These justifications include a belief, despite the evidence, that the failure rate only applies to “fad” dieting (or more, recently, a made up distinction of “self-directed” dieting,) false claims that the high failure rate is only from that one study from the 1950’s, suggesting that intentional weight loss is achievable by everyone, it’s just that the vast majority of fat* people since the beginning of weight loss just don’t do it right, or being honest that intentional weight loss fails long-term about 95% of the time but then claiming that you just have to keep trying until you’re in the 5% (making statistics teachers, statistics students, and amateur statistics buffs cry.) I talk about each of these claims in detail here.

The bottom line is that recommending that a patient lose weight and maintain that weight loss is far, far more wishful thinking (on the part ofweight-centric providers who wish for patient weight loss) than it is an evidence-based healthcare recommendation (and that’s before we consider that any health benefits experienced are likely due to behavior changes and not weight changes.)

Prescribing a healthcare intervention based on a rare best case scenario is an ethical issue. In part 2 we’ll look at how the advent of GLP-1 drugs for weight loss has taken this problem to horrifying new heights.

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*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings’ Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison’s Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.