Reader Question - If my patient asks for weight loss, don't I have to offer it?

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Reader Lindsay sent this question in, and it’s one I hear a lot from healthcare practitioners in the Q&As after my talks:

If I’m practicing patient-centered care, doesn’t that mean that if a patient’s goal is weight loss then I need to offer them weight management interventions?

This is a tricky question, and I’m not going to make a yes/no pronouncement, but here are some things to think about:

Per the NIH

The main objective of patient-centered medicine is to improve health outcomes of individual patients in everyday clinical practice, taking into account the patient's objectives, preferences, values as well as the available economic resources

Evidence-based medicine and patient centered medicine are not contradictory but complementary movements. It is not possible to practice patient-centered medicine that is not based on evidence, nor is it possible to practice evidence-based medicine at a distance from the individual patient.

The main point here is that patient-centered care is still grounded in ethical, evidence-based medicine.

The first question to ask, then, is whether or not intentional weight loss constitutes ethical, evidence-based medicine. I don’t believe that intentional weight loss meets the criteria of ethical, evidence-based medicine for several reasons (we have a quick sheet about this on the HAES Health Sheets.)

First, the incredibly high failure rate. If we are talking about behavior-based interventions, one question to ask is what else you prescribe that has a century of data showing a failure rate of about 95% and the opposite of the intended effect up to 66% of the time, and the result of that failure (in this case weight cycling) being strongly linked to multiple negative side effects including increased mortality rate?

Then there are the high failure rates and high risks of pharmacotherapy and surgical interventions.

Let’s look at a different scenario: A patient with chronic knee pain makes an appointment with you, their healthcare provider. They are super excited because they’ve just seen a TikTok telling them that anyone who believes strongly enough that they can fly can. They explain their plan to repeat “I can fly” whilst jumping off of a roof and flapping their arms really hard. They want your support of the plan since they are sure that flying will dramatically lessen or cure their knee pain.

Now, I know I said I wouldn’t make pronouncements, but I’m going to go out on a limb and venture to say that even though this is clearly what your patient wants, endorsing this plan as medically sound does not constitute patient-centered care.

I would suggest that patient-centered care here would be empathizing with the patient’s desire to be in less/no pain, but also, as their provider, explaining the risks involved in their plan, the low probability of success (remember, this patient is about 5% less likely to be able to fly than to succeed at significant long-term weight loss.) Finally, you can let them know that you are happy to offer alternative treatment options and that, while you can’t ethically endorse their plan of trying to fly and as a medical professional you strongly recommend against it, they absolutely have bodily autonomy and should they move forward and the highly likely harmful outcomes occur, you will be there without judgment to help the patient recover from them and consider other options.

Let’s go back to the weight loss example.

Because diet culture and weight stigma are so ingrained in our culture and healthcare system, the standard practice is that if a patient asks for weight loss help, their healthcare provider says “of course,” and/or a patient’s desire to lose weight in order to escape weight stigma goes unexamined and fully supported, even though weight loss is unlikely to work.

I would suggest that a patient-centered model allows the provider to slow this process down, gain an understanding of what their patient/client wants, and then provide ethical, evidence-based options in an informed consent/shared decision-making process, including information about the near-total long-term failure of weight loss interventions, including the failure rates and risks of pharmacotherapy and weight loss surgery as well as the risks of the weight cycling that is, by far the most common outcome. You can also discuss the benefits of weight-neutral, health-supporting behaviors. (Understanding that whether or not you feel that you can ethically offer weight loss interventions, and/or whether not you feel that you can refuse to offer them on ethical grounds, may be a complicated decision that will include things like where you work and in what capacity, and your relative power/privilege in that work.)

For more specifics about having conversations with patients/clients who want weight loss, check out this piece.  I also have pieces about informed consent conversations around behavior-based weight loss interventions, and weight loss surgeries and Medical Students for Size Inclusivity has a document around informed consent for GLP-1 Agonist drugs.

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More research and resources:
https://haeshealthsheets.com/resources/

*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.