The More Weight-Loss Treatments Change, the More They Stay the Same

Dear Readers,

Does this country make me look fat?

Americans are obsessed with weight. Sometimes it’s vanity, but sometimes it’s because so many of us really are overweight. While the country as a whole is a lot fatter than it/we used to be, finding an effective way to lose weight and keep it off has been a perennial issue for a long time.

At the turn of the last century, the famously fat President Taft was rumored to have gotten stuck in his bathtub. That’s unconfirmed, but, according to a report in the Annals of Internal Medicine, before he became president, Taft sought medical help to lose weight in order to relieve his heartburn, indigestion and fatigue. Some of the advice he got was good, and some was ineffective.

Sound familiar?

There’s a difference, of course, between carrying a few extra pounds and being obese. The former is less than ideal, but the latter poses several threats to your health. President Taft had his problems, but obesity also increases the risk of heart disease, stroke, diabetes, joint and muscle issues and certain types of cancer.

Taft’s goal under a doctor’s care was to lose 80 pounds; he lost 60, but at 255 pounds still would be considered obese for his height (6’2″). By the time he was inaugurated three years later, he weighed … 354.

Sound familiar?

This month, we look at why doctors still aren’t very good at helping us lose weight and keep it off, and what both patients and doctors can do about it.

The Size of the Problem

According to the Centers for Disease Control and Prevention (CDC), more than 1 in 3 U.S. adults and 13 in 100 high-schoolers are obese.

Obesity is expensive: According to the CDC, the estimated annual cost of obesity in the U.S. is $147 billion. In the last year counted, people who were obese had medical costs $1,429 higher than people of normal weight. (The numbers are for 2008, the latest year of compiled data.)

The difference between being overweight and being obese is quantifiable. It’s all about a number called the “body mass index,” or BMI, which indicates an individual’s amount of body fat. It’s not an ideal measure, because it doesn’t directly measure body fat, but uses a formula derived from your height and weight to render a relatively useful yardstick.

For most people (values are less useful for some buffed-up athletes and tall people), a healthy BMI is below 25. You’re considered overweight if your BMI is between 25 and 29.9, and anything over 30 is considered obese.

To calculate your BMI, link here to the CDC’s body mass calculator.

Searching for No-Fat Mr. Goodbar

While all efforts to lose weight center on food (and, often, exercise), there are more dietary schemes and weight-loss bromides  directed toward this goal than stars in the sky.

Everyone knows a regular diet of mint-chip ice cream and french fries is not going to pave the road to either health or a slim figure, but why isn’t the medical profession very good taking our healthful-weight consciousness to the next level, and managing our efforts to lose weight?

Often, the first medical professional overweight people encounter is their primary care doctor. But most primary care practices have size problems of their own: a lot of patients, a lot of paperwork (electronic or otherwise) and diminishing compensation from insurers. So, as noted in an article about managing obesity in the New England Journal of Medicine (NEJM), most of the primary doctor’s attention goes not to addressing the lifestyle issues–diet, exercise, sleep, stress, etc.–that often contribute to obesity, but to conditions they can treat with serial interventions and drugs.

It’s a circular problem, because many of those disorders, such as diabetes and high blood pressure (hypertension), can be a direct result of being overweight. “Obesity is often relegated to the bottom of the problem list: There are no wonder drugs, no useful biomarkers that define or predict prognosis, and no standard protocol that works for every patient,” the NEJM writers said.

Newer docs, according to the NEJM, frequently fail to recognize obesity, aren’t familiar with treatment options and don’t spend a lot of clinical time treating it.

A Prescription for Doctors

Treating obesity early and well begins with the academic establishment making it a priority in med schools. It’s a complex disorder with both physiological and behavioral contributors, and cutting-edge schools offer multidisciplinary courses that help doctors cultivate whole-patient treatment. “By integrating obesity education into the preclinical years,” the NEJM writers explain, they “encourage early inquiry into the biology and treatment of obesity.”

Some overweight patients might be better at carving out time for exercising, and adhering to a structured individual regimen; others are more motivated by group support, and might find more success from a planned-meal and counseling effort. Some, despite their best efforts with lifestyle changes, might be better suited for bariatric surgery (in which stomach capacity and/or intestinal absorption are reduced). Most people need a combination of weight-loss approaches, but there’s no single best practice, and it’s the doctor’s responsibility to know the options, know the patient and craft a customized plan.

It’s the essence of coordinated care, which is a treatment plan integrating the efforts of all of a patient’s medical and social service providers. (See my blog, “Lack of Coordinated Care Costs Time, Money and Sometimes a Good Outcome.“)

As noted in a story on MedPage Today, “The obesity epidemic can’t be successfully fought through debates about the ‘ideal’ diet, but by helping patients choose one and stick to it,” said researchers who wrote “A Call for an End of the Diet Debates” in the Journal of the American Medical Association.

As the costs of health care rise, insurers, including Medicare, increasingly reimburse medical providers on the basis of how well they keep patients healthy instead of counting up the number of  interventions they provide. “Our current training models are well equipped to produce physicians who can manage acute illness and the complications of obesity,” the NEJM writers conclude, “but if we expect physicians to shift their focus to disease prevention and management of obesity … physicians [must be] comfortable addressing complexity, motivating patients to pursue healthy lifestyles, and fostering collaboration…”

A Prescription for Patients

It’s the patient’s responsibility to acknowledge his or her weight problem and to seek help. If your doctor dismisses your efforts to do so by saying only, “exercise more and eat less,” or by reaching for the prescription pad without discussing your lifestyle, your sleep patterns, your family and work pressures, it might be time to find someone else who has the time and willingness to coordinate a weight-loss plan.

As the ultimate manager and recipient of this care, you can’t know too much about what’s involved in weight control. To learn more about achieving a healthful weight, the Centers for Disease Control and Prevention is an excellent resource. Start here, and here. The Weight-Control Information Network, an initiative of the National Institutes of Health, offers timely, science-based information on weight control, obesity, physical activity and related nutritional issues.


Here’s to a healthy 2013!

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Patrick Malone
Patrick Malone & Associates