What if weight loss informed consent is too discouraging?

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I was delivering grand rounds at a hospital, discussing best practices for caring for higher-weight patients. Part of the talk was a discussion of the high failure and risk rates of intentional weight loss (including behavior-based interventions, and weight loss drugs and surgeries.) In terms of behavior-based weight loss, I presented a timeline of about a century of research showing that the vast majority of those who attempt behavior based/lifestyle interventions lose weight short-term and regain it long-term which calls into serious question whether this constitutes an ethical, evidence-based healthcare intervention. I pointed out that if this is being recommended to patients, then they are ethically owed an informed consent conversation that explains these realities.

During the Q&A a physician raised her hand and asked me a question that I’ve been asked many times over the years. “I don’t disagree with the information you presented about the failure rate of behavior-based weight loss attempts, but I do disagree with what you said about informed consent. If I tell patients that there is about a 95% chance that they will lose weight and gain it back then they will never try, what good does that do?”

As I said, I’ve been asked this any number of times over the years. It’s also not just me, and not just healthcare providers. The late, great, fat activist Lynn McAfee was part of a US government task force whose goal was to create accountability for commercial weight loss companies. Lynn recounts that in a hearing, the FTC asked representatives from Weight Watchers to conduct studies lasting at least five years. The representative refused, saying “it would be too depressing for our clients.”

I won’t speak for Weight Watchers, but I believe the physician who asked me this (and the other providers before her) were well-intentioned. She was trained in a healthcare system, rife with weight stigma, to believe that weight loss is the most important thing for the health of higher-weight patients. Weight stigma, including implicit (subconscious) weight stigma, creates paternalism - the belief that part of her job as a higher-weight person’s doctor is to do whatever she deems necessary to convince, cajole, or (while she probably wouldn’t use this word,) manipulate her patients into attempting weight loss because she believes it is best for them.

In fact, this is exactly the kind of thing that informed consent is meant to prevent. According to the American Medical Association Medical Ethics Opinion 2.1.1, “Informed consent to medical treatment is fundamental in both ethics and law. Patients have the right to receive information and ask questions about recommended treatments so that they can make well-considered decisions about care.” Part of that process is the right to understand “the burdens, risks, and expected benefits of all options, including forgoing treatment.”

If a patient is told the realities of attempting intentional weight loss and decides that they don’t want to attempt it, that is the informed consent process working precisely as it is intended for both the physician and the patient. That, to answer the doctor’s question, is the “good that does.” It allows the patient to decide if they want to undertake an intervention based on the truth about the likelihood of success, failure, and risks of that intervention.

If a provider has to misinform, mislead, withhold information, or otherwise manipulate a patient into taking the course of action that the provider thinks is best for the patient, that is a failure of the informed consent process.

It is also a deeply unethical breech of the patient-provider relationship. Patients shouldn’t be expected to come to the appointment with their own knowledge, or with the ability to do their own research. Patients should be able to be certain that the healthcare provider they are seeing is trustworthy and honest and providing them with true and complete information, not misleading claims, half-truths, withheld information, or other attempts to manipulate patient behavior that exploit the provider’s position of authority, even if the provider is well-meaning in doing so.

It also creates situations in which patients believe their providers that significant long-term weight loss is likely for them. So, when they ultimately lose weight and regain it, they don’t blame the intervention, they blame themselves (sadly, often healthcare providers join them in that.) This, in turn, can create shame that leads to the patient disengaging from healthcare which means they miss things like preventative screenings, early diagnosis and intervention etc.

On the other hand, if the patient is told that this is an intervention that is rarely successful and that if they lose weight and then regain it they are having the experience of the vast majority of patients and that it’s not their fault, then when they (almost inevitably) have that experience, they are more likely to be clear that they didn’t fail the intervention, but rather the intervention failed them. This can lead to continued engagement with healthcare and the benefits that can come from that.

Patients deserve the truth about the recommendations that their providers are making, it’s as simple as that.

If you’re looking for support to deal with weight stigma at the doctor’s office, you can check out my March monthly workshop about exactly that. There is a pay-what-you-can option so that money isn’t a barrier. Details and registration are here!

If you want more information about informed consent, I have a piece about behavior-based interventions here, Medical Students for Size Inclusivity have informed consent information for GLP-1 weight loss drugs, and weight loss surgeries.

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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’