This is the Weight and Healthcare newsletter! If you like what you are reading, please consider subscribing and/or sharing! In Part 1 we discussed the basics of hernia repair for higher-weight people. In part 3 we’ll discuss the options for fighting BMI-based denials for hernia care. While I take the stance that people of all sizes deserve equitable care, in Part 2, I want to talk about the issues with these weight loss recommendations (this is a piece I’ve been meaning to write for a while so I’m incuding it in this series, but know that this isn’t just about hernia repair but about anytime weight loss is recommended or required for a patient to be “optimized” for surgery.) Today we’re going to look at it from the perspective of someone who agrees with these recommendations (which I d not) and/or of somene who is so desperate for care that they are willing to try to pay the weight loss ransom (which is a valid choice, but one that patients should never be coerced into making by a healthcare system that holds their care hostage.) Even in these circumstances, there are multiple issues with these weight loss recommendations including feasibility, side effects, and long-term prognosis. Feasibility and Side Effects The first question to ask is the feasibility of the requirement. “Optimization” for surgery doesn’t happen in a vacuum and it doesn’t matter if something would make the patient’s surgery easier or improve their outcomes if it is not possible and/or if it harms the patient more than it helps them. Despite this, the feasibility/likelihood of the patient experiencing the required weight loss is, in my experience, far too often not discussed or even considered. I have met with patients who were told they needed to lose 40% of their body weight whose surgeon told them to eat less and exercise more. This is an “intervention” for which about a century of research has found the likelihood of losing even 5% of body weight is quite low and the likelihood of maintaining it is incredibly small (though we’ll get to that.) The doctor might as well have told the patient to grow 6 inches to change their BMI sufficiently. Enter GLP-1s. Here again we’re seeing patients being prescribed these drugs not based on the drugs’ actual capacity to create (at least short term) the required weight loss but based on the sincerely held personal belief of the provider that any amount of weight can be lost with these drugs. In the recent research article that Angela Meadows, Louise Adams, and I published on GLP-1s for weight loss, we included tables in the supplemental materials that include information for all of the phase 3, placebo-controlled trials of GLP1-s for weight loss. One of the reasons I am glad these tables are out in the world is so they can be used in these discussions. As the tables show, about half of people don’t ever reach average weight loss in these trials with around 5-15% failing to lose even 5%. For semaglutide, the STEP 1 trial only looked at weight loss up to 15%, and 49.5% of the subjects failed to lose even 15% of body weight over 68 weeks and in the STEP 3 trial, even when combined with a restrictive diet, 64.3% of subjects failed to lose even 20% of their body weight over 68 weeks. For tirzepatid, the SURMOUNT 1 trial included weight loss up to 25% and 63.8% of the people on the maximum dose (15mg) failed to lose even 25% of their body weight over 72 weeks. In the 2-year weight loss analysis of the SELECT trial ( Ryan et al., 2024) 95.1% of patients failed to lose 20% of their body weight, average weight loss was down to 10%, and at four years the study had lost 89.5% of participants! Other studies showed significant loss of muscle mass as part of the weight loss. You can find the tables here in the supplemental materials. If you are being told to use GLP-1s to qualify for healthcare I also have a case study here that offers more information and some specific scripting that you can use. Then there is the recommendation for weight loss surgery. This is a surgery in which a healthy, correctly functioning digestive system is surgically manipulated into what would otherwise be considered a disease state in order to force restriction and produce weight loss. It is a very serious surgery with the potential for very serious side effects that can have significant negative impact on long-term quality of life and even be fatal. I wrote about the basics of these surgeries here. I also have a series about weight loss surgery and long-term quality of life in which researchers admit sparse and low-quality evidence, and that in multiple studies health-related quality of life was the same between those who had surgery and those who didn’t. At the bare minimum, giving the patient correct information about the likelihood of these surguries of actually leading to the weight loss that is being demanded in order for the patient to get the surgery they actually need is incredibly important when the patient is being refused a surgery that they need but recommended to undergo a surgery that alters an entire body system in a way that is, by and large, irreversible with potentially life-altering and even fatal side effects. A 2022 study called “Predictors for weight loss after Roux-en-Y gastric bypass: the trend and associated factors for weight loss” by Eghbali explains that while most people expect to lose more than 70% of the “excess weight” in reality the mean total weight loss is about 32% at 1-2 years. So, even if the patient is willing to have this surgery (and risk the significant side effects) and even if they could reach the mean total weight loss, that would still not necessarily be enough weight loss for the patient to qualify for the surgery they actually need/want. Medical interventions must be evidence-based and wishin’ and hopin’ and thinkin’ and prayin’ that all higher-weight patients will be outliers and experience more weight loss than the research suggests is likely (even in the short term) so that they can be seen as worthy of surgery is not ethical, evidence-based medicine. Long-Term Outcomes We know that the vast majority of weight loss attempts end in weight regain and that regain with GLP-1s has been shown to be even faster than with lifestyle interventions. Guidelines around weight loss for hernia repair typically brush this off with simple admonitions that amount to “don’t do that.” Given that intentional weight loss changes the body physiologically to induce weight regain, using the equivalent of “doctor, it hurts when I do this….well don’t do that” here again falls seriously short of ethical, evidence-based medicine. Even if someone believes that people could lose any amount of weight and maintain that weight loss, medicine must be practiced in the context of reality. That means understanding the risks of delaying the surgery while the patient attempts weight loss that research shows is unlikely to unlikely to ever happen, and considering the risks of weight regain on the surgical repair, which research shows is highly likely to happen. This is especially important given the existence of research for other procedures that finds that weight loss prior to surgery, including through weight loss surgery, does not improve outcomes. The sad reality, which is all too common, is that there isn’t enough research about hernia repair when it comes to higher-weight people. And as long as the healthcare system is comfortable allowing higher-weight patients to suffer and die unless or until they can comply with a directive to lose weight, those with power, privilege, and leverage to make change will need to do whatever can be done to fund and conduct the research that is needed so that people of all sizes can have equitable care. In part 3 we’ll discuss the options for patients who are dealing with BMI-Based Denials for hernia care. This month’s online workshop is Weight-Inclusive Sleep Apnea Management with special guest Dr. Lisa Erlanger! There is a pay-what-you-can option so money isn’t a barrier and all registrants will receive a video. Details and registration are here! If you appreciate the work I do here, you can support my ability to do it by becoming a free or paid subscriber! Liked the piece? Share the piece! More researchThe Research Post More resourcesThe Resource Post *Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings’ Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison’s Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this. Get full access to Weight and Healthcare at weightandhealthcare.substack.com/subscribe
