Someone I know is studying end of life care. She made me familiar with what is called “the surprise question” — a question put to a patient’s medical team asking if they would be surprised if the patient were dead in 6 months or a year. The answer can help guide treatment to meet the realistic expectations for the patient’s outcome. Because modern medicine is oriented toward treatment and more treatment until no further options remain, all too infrequently patients with little hope of recovery are submitted to considerable painful and experience a lot of suffering because of the notion that the fight must go on. Palliative care, on the other hand, is willing to acknowledge that sometimes what we need is comfort care not aggressive treatment. The surprise question opens the way to contemplate when is the time for palliative care.
Well, i have been intrigued by the power of this question ever since learning of it. And it occurs to me that a variant of it might be of use if applied to the care of fat patients. Bear with me here.
Recently two significant articles appeared in the New York Times, both about the failure of diets: After ‘The Biggest Loser,’ Their Bodies Fought to Regain Weight and Why You Can’t Lose Weight on a Diet. It is difficult to find a publication that better defines mainstream thinking about health and weight, yet here in the space of a couple of days were two well sourced, research based articles about the failures of dieting and weight loss in general.
From the second of the above referenced articles:
men with severe obesity have only one chance in 1,290 of reaching the normal weight range within a year; severely obese women have one chance in 677. A vast majority of those who beat the odds are likely to end up gaining the weight back over the next five years. In private, even the diet industry agrees that weight loss is rarely sustained. A report for members of the industry stated: “In 2002, 231 million Europeans attempted some form of diet. Of these only 1 percent will achieve permanent weight loss.”
Read that again, look at the odds: for women, one in 677. Pancreatic cancer, a form of cancer deemed essentially incurable, has a better 5 year survival rate than a fat person has of maintaining a weight loss. Yet chances are nearly every time a fat person sees a doctor what is suggested for whatever ails her is that she lose weight. The diet industry reaps billions of dollars each year while advocating something that will inevitably fail.
So, the surprise question. Let’s modify it and ask, “Would you be surprised if 5 years from now, your patient will be as heavy or heavier than she is now if she diets?” If the doctor is unaware of the failure rate for diets, then some education is called for.
Is it ethical to urge, cajole or try to shame a patient into a treatment that will almost certainly fail and in that failure cause more shame and suffering for the patient?