Making Patients With Obesity the Enemy Is Never Acceptable

Theodore K. Kyle, RPh, MBA; Caroline M. Apovian, MD; Amanda Velazquez, MD

Disclosures

February 21, 2019

Editor's Note: We invited the following letter to further the dialogue about a recent Medscape commentary that is taking place in our comments section and on social media. That commentary has now been retracted.

To the Editor:

In a recent Medscape commentary, Dr George Lundberg describes people with obesity as gluttonous and slothful —"pigging out." He dwells on foods like "whipped cream, root beer floats, banana splits," and other "anti-nutritious garbage." He depicts "really fat people shoveling down large quantities" of such food.

This kind of attack on a population of patients living with a chronic disease such as obesity cannot be tolerated. It is a vivid example of the weight bias that is prevalent even among healthcare professionals. Up to 40% of Americans live with obesity and should expect that health providers will help them with this common and consequential problem. The misperception that patients with obesity have excess body weight due to a presumed lack of willpower is unacceptable for healthcare providers. We must lead by example to bring an end to weight bias. Thus, a well-established medical education website such as Medscape should set the record straight and have zero tolerance for promoting weight bias.

The Immediate Harm of Weight Bias

An extensive body of research documents what people with obesity know very well. Weight bias does more immediate and devastating harm than the chronic disease of obesity itself. In caring for patients with obesity, we see this every day. Patients come to us with a long history of seeing health professionals who dismiss their symptoms. They routinely hear that whatever is wrong with them must be because they are not exercising enough or eating the "right" diet. In a recent example, doctors repeatedly told a woman with a 50-pound ovarian cyst that her only problem was excess weight. This continued for months. She sought help from multiple physicians, but they missed the diagnosis until an emergency physician finally found it.

If you think such substandard care is unusual, you would be incorrect. Research tells us that people with obesity get less care, including preventive care, than people without obesity. The care they do receive is less empathetic. Worse, physicians often neglect to provide preventive care to these patients. With such shabby treatment, it's easy to understand why these patients tend to avoid routine healthcare visits and more often seek care in emergency departments.

An Obsolete Understanding of Obesity

This problem springs from an obsolete understanding of obesity. Lundberg tells us that Julius Bauer "had much of this obesity issue pretty well figured out" in 1941. He is wrong. Research in neuroscience, molecular biology, nutrition, metabolism, clinical care, and a host of other disciplines tells a very different story.

In 1994, the discovery of leptin profoundly changed the scientific understanding of obesity. This hormone, secreted in fat tissue, conveys the state of nutrition of the body to the central appetite center in the brain. Building upon that discovery, researchers have uncovered many other hormones that control appetite and satiety in a complex network that becomes dysfunctional when obesity develops.

Research has demonstrated that hormonal changes result and persist for a lifetime —even after a patient has lost weight. These powerful forces reset the body to defend a higher weight, making obesity a chronic disease. Without chronic care, the body will return to an unhealthy higher weight and complications of obesity will progress. Because of all of this scientific progress, we know that many things contribute to obesity: interactions between our genes and our environment, gut flora, sleep hormones, and a long list of other factors. The list keeps growing as we learn more.

Thus, we can have no doubt that obesity is a complex, chronic disease resulting from innumerable factors. Yes, behavior plays a role. But it is only one piece of the puzzle and less influential than many people have assumed.

A Violation of Medscape's Mission

Medscape has always been an excellent source of medical education and current scientific research. But Dr Lundberg's recent commentary is a violation of the Medscape mission to offer expert perspectives and professional education. It presents an obsolete view that obesity is a condition caused by a lack of willpower. It conflicts with well-established medical literature and clinical guidelines for care. Presenting such an incomplete view serves to promote weight bias, as new research in the International Journal of Obesity has recently shown.

This commentary's degrading depiction of people with obesity, promotion of weight bias, and perpetuation of misinformation about the causes of obesity represents a violation of Medscape's community standards, especially because it will cause further harm to vulnerable patients. As healthcare providers, we must first and foremost do no harm. We hope that Medscape will choose to remove this content.

Ted Kyle, RPh, MBA
Caroline Apovian, MD
Amanda Velazquez, MD

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