First Do No Harm

Returning to the office for the New Year I decided to clean up my bulletinboard. My thinking was that if it’s buried under layers of paper, it’s probably irrelevant by now. If not, it may be something past due for attention.

I found one article of a type I periodically put there, that doesn’t seem to have immediate application but which could be filed under “there’s something here before you throw it away.” So, I had a few thoughts before throwing it away.

The article was published June 2023 in Radiology under the (clunky) title: “Two year Skeletal Effects of Sleeve Gastrectomy in Adolescents With Obesity Assessed by Quantitative CT and MR Spectroscopy.”[1] The article and its recommendations caught my attention, as it seems to encapsulate so much of what is wrong in current medical culture.

The researchers studied effects of weight loss surgery (sleeve gastrectomy) for obese adolescents. They found that their patients, from 13 to 24 years old, experienced an average drop in bone density of almost 12% two years after their surgeries.

The lead author noted this could cause real problems for his patients later in life (osteoporosis, fracture risk, etc.). Therefore, he recommended that bariatric surgeons (who perform these surgeries) should “increase awareness” of bone health. And, he recommended these surgeons engage in more “monitoring of bone mass” (periodic CT scans), use more post operative dietary supplements (vitamin D and calcium) and initiate medication therapy “when appropriate” to increase bone mass.

Statistics vary, but most authorities agree U.S. adolescent obesity has increased several fold in the past decades: from approximately 5% in the 1976-1980 to approximately 20% today.[2] This would imply that the majority of adolescent obesity is preventable by modified behavior.

Of course, all obesity is not 100% behavioral. It is currently thought to include a component of genetics, which is also not uniform among ethnic groups.[3] The ethnic makeup of the United States has also changed in the past decades, including higher proportions of Hispanic descent, thought to have a higher predisposition to obesity as compared to some other groups. However, other scholars feel that genetics or ethnicity may be over-emphasized, and even if
contributory, is likely not determinative for the vast majority of individuals in any group.[4]

But what impressed me most about the article was not the increased incidence of adolescent obesity, but just how far established medicine has strayed from the “First Do No Harm” paradigm that has been central to medical ethics for over 2000 years, and which is still (in some places) taught in American medical schools.

The ethics of “First Do No Harm” are indeed more complex than they may first appear. The translation from original Greek is not without controversy. One must also incorporate risks of non-action into any decision, etc. But the central idea of “First Do No Harm” still seems to follow from:

1. A healthy respect for the complexity of human physiology.
2. A small dose of intellectual humility (i.e. how little even current medicine understands it).
3. Appreciating that a major intervention in this complex process will likely produce secondary, tertiary, unknown, and unpredictable consequences (short and long-term)

Therefore, the basic idea of “First Do No Harm” still seems sound i.e. a wise physician does well to intervene less drastically rather than more, particularly when there is no compelling reason to do so.

So, on one level, it may have been surprising to surgeons in 2023 that reducing the stomach capacity of obese adolescents can result in significant bone loss down the road. But on another level, it should not have been surprising at all that drastically changing organ anatomy of an adolescent, even with good intentions, was bound to have unintended, potentially harmful effects that might only be discovered years later.

The most telling part of the article was the “take away” conclusion of the lead author: to the effect that surgeons doing sleeve-gastrostomies for obese 13-year-olds should do serial CTs of their patients (to monitor bone density) and intervene with medications to mitigate post-operative bone loss. That is, the lesson drawn seems to have been that when doing drastic (arguably unnecessary) surgeries, the surgical community needs to “up its game” on how to handle the complications.

One could fairly ask if a better conclusion should not have been a reminder to our medical community to revisit the “First Do No Harm” ethic. If U.S. adolescent obesity was 5% before 1980, and now hovers around 20%, then perhaps before engaging in organ-altering surgeries, the medical community should reflect upon whether non-medical behavior that reliably forestalled 95% of childhood obesity until recently could be emphasized, and behavioral issues exhausted, prior to engaging in surgery.

This is not “fat shaming” (sometimes invoked on this topic). Closer to my intent is “doctorshaming” or more accurately “institutional medicine shaming.” Our medical culture (and medical economy) makes it difficult for most primary care doctors or pediatricians to have the time for detailed engagement and follow up with their patients — if they even have a good knowledge of nutrition and exercise physiology themselves.

And, to be somewhat cynical, it is often more profitable for institutional medicine to engage in medical intervention, which requires additional treatment to manage its complications, than to engage in effective preventive care.

One could pull on many “threads” here, including the role of processed foods in obesity trends.[5] But I thought this piece of paper was worth thinking about before clearing it off the board for 2024.

–Laurence M. Deutsch

  1. “Two year Skeletal Effects of Sleeve Gastrectomy in Adolescents With Obesity Assessed by Quantitative CT and MR Spectroscopy.” Huber et al, Radiology (6/13/23).
  2. US Environmental Protection Agency (; Centers for Disease Control (
  3. “Obesity and genetics,” Golden et al, J Am Assoc Nurse Pract 2020 Jul; 32(7):493-4956.
  4. See, e.g. “Genes are not destiny.” Harvard T.H. Chan School of Public Health.
  5. “Processed foods highly correlated with obesity epidemic in the U.S.”, GW School of Medicine and Health Sciences (1/5/20).