Dr. Goldacre is a British physician who rails against quacks and bad scientists generally. His book, Bad Science, is a funny, insightful, merciless critique of lazy and dishonest scientists, as I expect many readers of Science 2.0 already know. I think he's on the right side of almost every argument he's engaged in (and he's engaged in several, at most times). So it troubles me that he might consider what I did in practice and the science that I write about currently, as quackery.
While practicing "obesity medicine" for four years, I wrestled over this notion a number of times. I don't ever know what people mean by the term "nutritionist," because I don't really know what the term means. There are dietitians, physicians, counselors - what exactly is a nutritionist? We use the term here too (so it's not just a British-U.S. translation problem), but I've never met one. From reading Goldacre's blog and watching some of his interviews, it seems that he's mostly concerned about folks who peddle weight loss solutions using pseudoscience and even fake degrees from non-existent institutions. So maybe I'm safe - I'm not doing that. But he goes on to state things of the this nature, often:
"And the grandiose nutritionism-peddling columnists from Sunday magazines, even if they do recommend you eat some particular nut because it contains lots of vitamin G and selenium, are still basically recommending fruit and veg. Everyone knows basic dietary advice, and they don’t need a nutritionist, doctor, alternative therapist or journalist, to tell them. They need their mum." ---blog post 6/2/05.
So the question, for a doc like me, is whether the whole idea of doctors practicing "obesity medicine," even when we aren't advocating for our favorite vitamin or magic ingredient, is legitimate; or is it all just practicing quackery?
Source: The Brady Family Rubber Ducky, shown here in repose.
Let's begin to answer this quackery charge by observing that in the U.S., there is no legitimate obesity specialization on a residency or fellowship level. This is not to say that there won't be soon. The board of medical specialties didn't recognize Family Practice until the 1970s, so these things do change as practice models change. But, currently, you could not choose to be an obesity doctor (bariatrician) coming straight out of medical school. To become an obesity doctor, you currently need to do a full residency of some sort, then go find extra training. This is to say, you are not practicing in a recognized, accredited field when you say you practice bariatrics, obesity medicine, or (cringe) weight loss medicine.
There are two major societies supporting continuing education conferences to help physicians learn some obesity science. I've been a member of both at different times. The American Society of Bariatric Physicians (ASBP) is mostly geared toward helping primary care doctors improve their treatment of obesity related conditions and helps them determine how to offer "weight loss," to existing patients.
At ASBP conferences, one can learn the basic science that underpins weight regulation: some endocrinology, some nutrition, some neurology, some behavior. Indications for when to use medications and when to consult bariatric surgeons are taught. The society promotes best practices, advocates against dangerous or silly treatments (like HCG) through position papers, creates free downloadable algorithms, etc. Successful weight loss doctors and researchers active in the field are members and run the meetings. They orient you to history, including the history of mistakes like Fen-Phen "pill-mills" and teach one how not to fall into becoming the "wrong sort" of weight loss doctor. This is the more practical of the two societies. This is where you learn "how to do it."
The second society is dubbed simply "The Obesity Society." It is heavily skewed toward research and the yearly conference is a bit closer to what you'd experience at the scientific conferences of any sub-specialty: you would be bored out of your mind unless this was your passion. The Obesity Society is the parent organization running the journal Obesity which contains the same legitimate science you'd find in any peer-reviewed journal. That's not to suggest that ASBP is not scientific, but TOS, in my opinion, is more research-oriented and ASBP more practice-oriented.
Both of these societies are now offering "board certification," by testing through a central authority called the American Board of Obesity Medicine. This is not the same as being board certified in one's specialty, which denotes that a physician has done between one and six full time years of extra work after internship. These certifications are tests that one can take after a moderate number of hours accumulated at conferences (over a couple years) along with some mentoring.
How consumers are supposed to know that physicians promoting themselves as "board certified" from these societies is not equivalent to the way the term is used for something like "board certified neurosurgeon," I'm not sure. The term borders on misleading, in my opinion. A "certificate of additional training" from the "society" rather than "board" would more accurately reflect what the doctor has gone through.
That being said, the two societies point out that this is how new specialties become recognized: bringing together scientists and practitioners with common interests, educating new members, increasing research funding, setting practice standards...until teaching hospitals begin to create fellowships and full residencies. Obesity medicine is likely in this transition.
But is what is taught and practiced quackery, in the Ben Goldacre sense? I would answer with a definitive "No." The science is certainly not quackery. It's about digestion, metabolic pathways, neuro-endocrine signalling, exactly as you'd expect. However, we run into some problems when we try to figure out how one is supposed to put any of this scientific knowledge into practice.
Contrary to what some might think, becoming a weight loss physician is not an easy path to riches. Since there is essentially no insurance reimbursement for the activity, one is either forced to bill weight management as lifestyle counseling (for $15 per half hour visit) or bill under whichever disease a patient has that is co-morbid, such as diabetes. But one doesn't get any "extra" reimbursement for choosing to treat diabetes with a diet program in addition to writing a quick prescription. Because it is so difficult to get reimbursed for anything other than writing a prescription, the ASBP does run a two day conference helping one get started on the business of running a clinic based on behavior modification: motivational interviewing, journaling one's food, exercise prescription. The "business" teaching can feel a little...bourgeois....or maybe gauche...(I don't know why there isn't a word in English for this)...to physicians who aren't used to considering medicine a business.
In addition, there are certainly are some physicians who decide to chuck the whole idea of insurance and run a "cash only" weight loss clinic. We have several words for this in English and I will let the reader choose one mentally as I point out that the way that one gets paid does not, in and of itself, mean that the physician is practicing quackery. You can't run a business without being paid and so far, insurance essentially does not pay U.S. doctors for this work.
But to be a quack, one has to hold scientifically unsubstantiated views and to espouse them to less educated consumers of health care, frequently for self-gain. I haven't run into this in the medical colleagues I've met at these meetings. The practitioners and researchers at society conferences are just professionals who see a need, care about people's health and think that this condition deserves more attention. They see what obesity does to the lives and health of their patients and they want to help through educating themselves on how the condition arises and what are the best treatments...sort of like normal medical practice.
Sure, there are always oddballs in a large society. There can be the occasional lecture with a contrarian view that goes against established science, such as contending that many more people need testosterone treatment, or Vitamin D, or thyroid hormone, than are currently getting it. In the past, I've attended some talks that could rightfully be categorized as disease mongering as well, with suggested changes of thresholds for obesity definition, or certain nutrition deficiency states. Fortunately, this is rare in obesity science education. Most importantly, the societies promoting that we take the condition of obesity more seriously wish to apply the same scientific rigor to studying weight problems as everything else. They are what will lead us away from disease mongering and quackery, not toward it.
An important question, for the consumer, or to a colleague considering a referral, is whether THIS weight loss doctor is a quack.
Warning signs might include:
- Selling products for cash in clinic
- Advertising a "program" that runs for a period of time
- Storefront location, rather than traditional clinic location
- A single answer for all cases of obesity
- Use of medications off-label
- Use of "alternative" weight loss treatments like teas and supplements
- Excessive advertisement
- All patients are given standard expensive battery of lab tests, regardless of whether their record already has tested sugar, thyroid, lipids, etc. Or, unusual tests are run to look for trace nutritional deficiencies.
There are, of course, exceptions to all of these. In large cities, storefront locations might be what's available, providing some supplements to counteract a very low calorie diet program might not be mercenary, etc. Everything in its place. But you should have the feeling that your "weight loss doctor" is actually acting like a doctor. It should feel like a regular clinic, not a GNC. This is mostly a list of things that show the doctor is putting a commercial interest ahead of good medical practice. It doesn't guarantee quackery. But where there is too much commercial interest, the patient's health is likely at risk.
Signs that your weight loss doctor is legit:
- You have a normal office visit in a clinic
- You have a medical history taken
- You are examined - like, the stethoscope part, not just height, weight and skin pinching
- Treatment advice takes into account your age, goals, medical problems, history, medications.
- There should be shared decision making which includes not trying things that have failed you in the past.
- Medications should be optional and adjunctive to treatment. You should not be showing up once a month to get your "diet pill" prescription.
Things that would reassure me:
- My own doctor referred me
- The doctor has privileges at the local hospital
- He/She can account for his/her interest in obesity as a medical problem
- Doctor has an interest in the diseases that parallel obesity: heart disease, PCOS, infertility, type 2 diabetes, lipid problems. If your doctor is only interested in pounds on the scale, do you really need a doctor?
- Membership in either the American Society of Bariatric Physicians or The Obesity Society
Another way to know if you've come to the office of someone with an actual interest in the condition of obesity is by looking around the waiting room. Do you see big people there? Are there people in wheelchairs? Sick people, like a normal doctor's office? Or is it full of the worried well, trying to lose 10 pounds? Real doctors enjoy the challenge of sick patients and there should be signs that your obesity doctor is actually helping those who need it most.
Getting back to this issue of whether you need a doctor or a "mum" to address obesity...I'm going to just cut Ben Goldacre some slack and assume that he is not purposely trying to denigrate people or deny that there is real pain associated with severe obesity. I'm going to assume that he understands that there is a tremendous wealth of hormonal and neurological complexity underpinning food intake, appetite, energy regulation and digestion. There can't really be a debate about whether metabolism is a legitimate scientific subject of inquiry: it's using the same biology, physiology and pathophysiology as all the other fields we docs spend our time worrying about. I'm going to assume that it's not obesity that he thinks we should talk to "Mum" about, but weight loss. Or even more specifically, "how one should eat."
Do we need to go to a doctor to find out what and how much to eat? Should the doctors who become knowledgeable regarding mechanisms of adipose tissue regulation and energy balance spend their clinical time doing weight loss counseling? Probably not. I personally happened to be kinda good at counseling people how to eat, when I did it, but that part of the job is not really medical practice. Medical practice should consist of diagnosing and treating illness. I was educating, coaching, coaxing, cajoling, commiserating....but not really treating a "disease."
Does this mean that doctors should leave all questions regarding obesity to Weight Watchers and other commercial problems, since much of it is not medical? Absolutely not. We need doctors to take an interest in this science to help people avoid wasted time and dangerous programs. We need doctors educated enough in what actually works that they can persuade patients, using rational scientific explanations, against silly liquid diets, detox regimens, fasts, highly restrictive programs, all the fad nonsense. But we can't do this if we haven't actually studied any of it. Ideally, a physician should know enough to direct a team that includes a dietitian and a health coach, but the physician should not get confused (as I often did) and begin to actually do those jobs.
Should there be a specialty of Obesity Medicine?
When I see how The Obesity Society and the ASBP have grown in the decade I've been attending their conferences, I have little doubt that we are effectively building a new specialty around this condition. It is specialized knowledge that gets taught. When I discuss anything about obesity in any detail with another physician, it is clear that the field contains its own terms and knowledge that are not part of general medical training. Like any field, there is jargon and minutia that don't translate directly to patient care and aren't necessary for every doc to know. There needs to be a group of practitioners using the new knowledge.
As the basic science knowledge base grows regarding obesity, we are getting a very clear picture of pathways that control normal regulation and what goes wrong with these normal biological processes as someone becomes obese. This is how the scientific method informs medical practice. It's not the science of how to remember to eat your fruits and veggies that the researchers are examining. Nor is it quack theories about trace minerals and anti-oxidants from pomegranates. It's cell biology, biochemistry and pathophysiology they are elucidating.
That being said, I still don't see why we need to create a new specialty around this particular condition anymore than we create a specialty solely around diabetes, high cholesterol or hypertension. Obesity fits just fine within known medical science and there is one specialty that is perfectly situated to take control of its management. There is one specialty that has chosen to neglect this responsibility and has left it to a collection of scattered scientists and primary care doctors to assemble the ASBP and TOS. I'll give you a hint: obesity has to do with regulation of tissues, regulation of nutrients, signalling between cell types, organs that secrete stuff and sometimes get dysfunctional....
You guessed it! Endocrinology is the field that should be treating this condition!
Where the @#$! are the endocrinologists in this picture? Why is obesity not a simply a sub-discipline within their field? Why don't they include obesity medicine as an integral part of their education and ongoing training after residency? Why is there not a two-year fellowship for endocrinologists after they are done getting trained in rare stuff they will never see after they leave their tertiary training center?
Currently, if you go to an endocrinologist to be worked up for excessive weight gain, they make sure your thyroid is normal, your adrenals and pituitary don't have tumors, then send you back to your primary doc with the answer that you don't have an endocrine problem. What type of problem is excessive growth of a certain body tissue type due to internal regulation abnormalities, if not an endocrine one?
Granted, there are some endocrinologists involved in important ways in the societies I've discussed above (in some cases running things), but why are we training a whole new population of semi-endocrinologists in the pathways of energy regulation and how the brain responds to bodily needs and signals when the endocrine docs already know this stuff better than we ever will? Perhaps we still feel obesity is a moral failing. Maybe we are still biased against treating heavy people with respect. Are we afraid that if we call it a "disease" all will be lost? I'm not sure I know the answer, so I leave it for readers to ponder.
Let's be clear: some people are 200 pounds overweight. They need doctors who understand what's different about them. In addition to the strictly endocrine aspects of obesity and its ubiquitous cousin Type 2 diabetes, there are a host of co-morbid conditions, including polycystic ovaries, non-alcoholic fatty liver disease, obesity hypoventilation syndrome/pulmonary hypertension and lymphedema of the legs, that need treatment. I see no reason why the focus of continuing education for primary doctors interested in obesity should not focus on these manifestations of increased weight. Lymphedema does not go away with diuretics and we need to spread distinctions like that more broadly to the doctors that see patients regularly. This would be a better use of training time than learning weight loss tips.
The societies could perhaps be re-worked toward making us all better obesity doctors and we could leave "weight loss" to the counseling and coaching professions until medical science provides us better answers and treatment for our patients' obesity.
---No ducks were harmed in the writing of this post---