Saturday, September 08, 2012

You're Too Fat!

We hear a lot about obesity and weight control these days: eat less, exercise more.  Our first lady is very interested, and it's fashionable to believe that more vegetables and less TV will make one thinner.  I say "to believe" because we really don't understand the role that exercise has in weight loss and, at least for some people, exercise alone is not enough to drop those pounds.  

What role do, or should,  doctors have in solving this epidemic we have of overweight and obese Americans (now 2/3rds of adults)?

Over on KevinMD, Dr. Arya Sharma blogs about why weightloss advice may be unethical: he notes that patients regain weight,  that advice is unethical, and that while weightloss may alter measures of risk, we don't have hard evidence that losing weight increases longevity.  Oh, and then their is the issue of sensitivity.

Yesterday, on Talk of the Nation, Neil Conan and his physician guest, Dr. Ranit Mishori, talked about how doctors address the issue of weight problems with their patients.  I listened to 20 minutes of the 30 minute broadcast, the link will let you listen, too.  The first person to call in noted that she had uncontrolled hypertension, she's 20 pounds overweight (despite power-walking 5 miles/day), has trouble controlling her eating, and her doctor reads her the riot act about how she has to get her weight under control.  Her response, despite continued high blood pressure readings, is to avoid the doctor, cancel and delay appointments, and to feel badly about herself.  The second caller said his doctor yelled at him for a half hour to the point that he cried and his response was to lose 110 pounds, which he has kept off.

Finally, there was recently a study in the journal Obesity which shows that overweight physicians are more likely to address weight/diet issues with obese patients than are physician who are overweight themselves. What the article doesn't say is whether patients are more likely to lose weight if their doctor (slim or not so slim) discusses the issue with them and encourages lifestyle changes.

If we had effective treatments for obesity, I think I would be more enthusiastic about encouraging doctors to be more engaged in weight loss, or first ladies' to promote growing vegetables, or mayors from banning super-sized sodas.  As is, we have little to offer, psychiatrists and their medicines are certainly part of the problem for some folks, and those people who do lose weight and sustain their weight losses (a small percentage) are often self-motivated.  While I only heard the call-in patients' side of the story on the NPR piece, I was appalled that it sounded as though this patient was being told she must lose weight for adequate blood pressure control -- it seems to me that patients with illnesses that can be abated or controlled with lifestyle changes should be counseled to do so; if they don't or can't comply, then they should be offered aggressive pharmacologic treatments.  I know many thin people who require 3 anti-hypertensive medications to control their blood pressure, and many slim diabetics who require multiple medications.  And perhaps this patient's doctor is offering medications, but her presentation led the listener to believe that her physician feels her hypertension is her fault and there is little to do if she won't diet.