An Iatrogenic Condition

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Joanne and I were watching Shark Tank the other night and I found myself wondering if the negotiations and business analyses might be so bogus that venture capitalists and MBAs get a good chuckle out of the reality show. Maybe real estate agents, general contractors, and interior designers watch Love It or List It and shake their heads. Since these programs cover topics outside my area of expertise, their content could be spot on or largely misleading and I might not know the difference.

Yesterday, the New York Times exposed the Biggest Loser for some of the long-term harm it does to its contestants and the unrealistic expectations it sets for viewers. Most notably, weight regain is pervasive despite the ex-contestants’ best efforts to keep it at bay.

For myself and other practitioners who use a similar approach to ours, some of the minutiae may have been new to us, but generally speaking, the Times piece went right into our “Yeah, no sh-t” folders, as we have known the show to be fraudulent and problematic since its inception.

Having said that, it occurs to me that for readers whose expertise lays elsewhere, this might have actually been news. If that includes you, and you were surprised to learn about the contestants’ weight regain and struggles, I hope you do not feel gullible. How were you supposed to know?

However, any seasoned obesity or metabolism researchers who found themselves surprised by these results ought to be embarrassed. Data showing commonplace weight regain among people who attempt to lose it has been available for quite a while. Even some of the most ardent weight-loss supporters reluctantly admit that although we have several methods of inducing short-term weight loss, we have no idea how to produce long-term weight loss for more than a tiny fraction of the people who attempt to achieve it.

What we see more commonly, not just in Biggest Loser contestants, but in people across the board who attempt to intentionally lose weight, is ultimate weight regain that often exceeds their baselines.

As an example, consider the following growth chart, which is from a real patient of mine (All information that could possibly reveal her identity has been removed.) Looking at her chart, hazard a guess as to when her parents and doctor first attempted to intervene with her weight. Do you think it was at age 17, when she first came to see me?


No, it was just after age eight, when her BMI-for-age, which was in the 92nd percentile at the time, was deemed a problem. She was naturally a bigger kid, okay, but this fact’s implications have more to do with stigma than health. The focus on weight and a belief that an intervention would help to lower it created an iatrogenic condition. In other words, her weight became a problem because it was viewed as one.

Not only was the diagnosis off base, but the attempted interventions worsened the problem. The first diet produced a slimmer 10-year-old, who subsequently rebounded into a chunkier tween. Based on the research, this was to be the most likely result. As the patient’s teenage years began, subsequent attempts to lower her weight produced similar patterns of weight gain.

They took a child in the 92nd percentile and dieted her up to the 99th percentile, and in the process screwed up her relationships with food, her body, her doctor, and her family, all of which she is now working hard to untangle and fix.

None of that was the child’s fault, nor are the parents to blame, for they were just doing what they thought was right by following instructions from trusted practitioners.

And really, I do not blame the doctor either. Pediatricians and other primary care doctors are tasked with a tremendous responsibility to maintain basic knowledge about a myriad of conditions, everything from sore throats, to sexually transmitted diseases, to early signs of cancer, but this very demand limits them from being experts in any one field, including weight regulation.

The chain of education and direction has to begin somewhere. While these data on Biggest Loser contestants might have come as a surprise to laymen, the researchers who are responsible for the foundation of our healthcare policies should have seen them coming. That it took a New York Times article to wake them up is shameful, but they sure seem to be paying attention now, at least for the time being.

4 thoughts on “An Iatrogenic Condition

  1. Thank you, Jonah, for a great article. I hope the Times’ stature will serve to open mainstream minds, even if just a little.

    I found your site through Joanne’s amazing post on ASDAH regarding the “WW sister,” and wanted to extend encouragement and thanks for her courage as well as recognize the ongoing challenge of living with family who are unwittingly destroying the bonds which are supposed to be supportive. It’s all too common.

    Keep up the great work. After all, it wasn’t that long ago that people were being bled for everything from headaches to syphilis. I try to remember this when walking through the hallway to the office in the hospital where I work, passing by the huge posters showing average-sized women (of course) standing on scales, biting their lips, “realizing” that their solution, of course, is bariatric surgery. Barbaric is what I call it instead.

    It’s hard to conduct my short, round, overweight body with an off-the-charts BMI through these halls and remember the truth: that evolution, nature, healthful eating, moderate exercise, rejecting negative messages about body size, and trying to replace the onslaught of all those “medical” “certainties” with words of self-solace, self-care, and self-love is what sustains and improves health.

    • Hi Sondra, thank you so much for your support and sharing a bit about your own story. When I was younger, I assumed that our culture, including our healthcare system, had figured itself out and we no longer had to deal the patterns of human behavior and thought that historically held back progress. Oh how terribly wrong I was.

  2. Oh, man, this rings bells for me.

    I’ve mentioned before that one of my parents was the patient (victim) of a ’70s-era experimental obesity clinic run by a then-famous nutrition expert. (He’s now a snake-oil peddler, pushing things like coconut oil for “generating ketones.”) I was shoved into following every experimental therapy they were given, with the exception of liquid protein, which were mostly nonsense, including a version of “stocking” which encouraged people to gorge themselves on “forbidden foods,” and spending 15 minutes a day staring at yourself in a mirror to understand why you’re ugly and need to change.

    This bull started when I was about 11. Now that I’m in my 50s and morbidly obese, people blame me for it. I’m obviously sitting around, never moving, always eating, because that’s what tv shows like “My 600 lb life” tell them, while The Biggest Loser tells them that if I just worked harder, I’d lose it all.

    Frankly, I’m delighted that this stuff is making the mainstream press, because it’s drowning out the “but, but, calories in/calories out!” dingbats. The articles are repeating stuff that obesity researchers have been saying for ages — that dieting slows metabolism, which can stay slow for years if not permanently, that the brain will send signals to try to encourage weight regain, that “stress hormones” like cortisol promote fat storage and can cause weight gain independent of food intake (“you can’t generate fat out of nothing!” misunderstands the complexity of metabolism and nutrition), that many factors outside of obesity are more indicative of mortality, and of course that 95% of diets fail, often with regain (oh, man, the best bull response I’ve heard to this is, “They don’t include successful dieters in those studies!” which, WHAT?!), are all being yelled out loud.

    Of course, I suspect the people who study obesity who start off with the presumption that “obesity is always unhealthy, period!” will be making waves soon, and insisting that all fat people must lose weight, no matter what.

    • We are really glad to see this information becoming more mainstream. All of the efforts that people around the world have been putting forth for years (Unfortunately, people are reluctant to listen when you are telling them something they do not want to hear.) contributed to what we hope is a tipping point. On the other hand, you are probably right that weight-focused folks will find a way to spin this. Money and cognitive dissonance are powerful forces.

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