Yesterday’s Times offered two distinct perspectives on weight loss. One, a detailed feature on gastric surgery by Anemona Hartocollis, details the plight of a young obese woman who opts for Lap-band surgery. In this procedure, surgeons wrap a constricting band of silicone around the stomach so that patients will feel full upon eating less food than they might otherwise. Allergan, the company that manufactures the device, admits to these complications on its website.

The other, a discussion of resolutions and will-power by John Tierney, considers strategies for sticking to diets, exercise regimens and other good intentions for the new year. Within this piece lies a distracting story of an obese (375 pound) hedge fund manager whose gastric band failed to keep his appetite in check. When he landed a project in Las Vegas and feared regaining weight, he aimed high – to lose 100 pounds, outfitted his hotel suite with a gym, and hired a personal trainer to stay nearby and keep him on track in terms of meals and exercise. This costly “outsourcing” of will-power is, obviously, not an option for most people.

Tierney does offer some reasonable suggestions – like setting realistic goals, weighing yourself daily, Tweeting your weight, logging into a weight-loss website, not freaking out if you blow your diet one day, etc.

Both articles are well-worth reading.

But here’s the thing – how do doctors fit into this picture? In the last few years that I was practicing hematology, I saw a few patients who had B12 deficiency after gastric bypass surgery. These patients turned out to have multiple problems after their stomachs were cut so they’d eat less food. For some it was helpful; I saw individuals who lost over 150 pounds. Still, the surgery was huge and risky. I can’t fathom having recommended it to a patient whom I cared for, unless perhaps I’d personally witnessed her struggling to lose weight for over, say, 8-10 years.

Because most people, if inspired or starved, can lose weight. This may sound cruel, but what if the doctors recommending the procedure don’t have sufficient confidence in their patients?

The Lap-band is sold as a safer alternative, but upon reading the story (an anecdote, but telling), you have to wonder what are patients’ expectations of the procedure, and how well do they understand the likely risks and benefits. Who are the doctors who tell them about the procedures, and what are their ties with industry (besides the obvious link of surgeons who do the surgery and recommend it).

Like patients with cancer, patients with obesity may feel desperate. But unlike cancer, obesity is almost always a function of choices we make, and for which I think we have to hold people responsible.

Doctors, maybe, should expect more of their patients. “Yes, you can lose 30 pounds over the next 2 years,” one might say. And they might talk about strategies, Tierney-style or otherwise, based on the patient’s preferences and personality. “Come into my office once each month for a weigh-in” might be very effective in persuading patients to shed pounds. A technician could do the monthly measurement in the office or medical home, and the doctor or nurse might follow-up with an encouraging email. Imagine that!

So why don’t more general practitioners, including pediatricians, offer this sort of weight-loss approach? Is it too simple a strategy that doctors don’t find it interesting? Or not sufficiently profitable for the office or medical center?

No answers, just thoughts upon reading, for today –

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