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.


Anonymous said...


Lisa G said...

Interesting post. I saw the KevinMD post as well. I am over the whole MD getting on my case about my weight thing....considering I take Seroquel, being thin ain't never gonna happen, so to speak.

I always find it hilarious that my super-thin psychiatrist has the nerve to lecture me about my weight, while handing out the AAPs.

jesse said...

Dr. Sharma's blog is totally bizarre: it is "unethical" to advise patients to lose weight primarily because it does little good and may upset the patients. I guess that all the ministers who urge their flock to not sin are likewise being unethical.

There is no question we are in an overweight epidemic. Have you ever been traveling in Europe and saw a group of tourists a block away, whom you correctly deduced were American from their shape?

I think the problem comes primarily from our junk fast foods, chips and fries. Eating certain foods is like an addiction. Europeans eat differently. If they adopt our eating habits, their weight will change, too.

And at the same time all of this is going on, magazines routinely photoshop thin women to make them look even thinner. Anorexia among teenagers is an epidemic, too.

Nobody ever intends to become fat, just as nobody drinks with the intention of becoming alcoholic. But alcoholics often deny their disease, while in our thin society no one needs to be told he is overweight. In that, at least, Sharma has a point.

Anonymous said...

"which shows that overweight physicians are more likely to address weight/diet issues with obese patients than are physician who are overweight themselves."

Dinah said...

So I don't think it's "unethical" but I do think that we are short on what we have to offer as treatments, and that while it's perfectly reasonable to point out that lifestyle changes may result in better health, that both the delivery of the message and the sensitivity of the recipient are important. Many overweight people know they are heavy and want to be thinner, and hearing it from a doctor in an insensitive, blaming, unsympathetic, it's-your-fault, style may serve to shame the person. I think Dr. Sharma may have a point that it does little good and may upset the patient, and while "upsetting the patient" may not be awful, well it is if the patient is so shamed/self-conscious that he simply does not get medical care because a) he doesn't want to be reamed out or b) he figures his health problems are his fault.

Blaming fast food is too easy. There are many heavy people who don't eat fast food and there are many fast food eaters who are not heavy.

Europeans are also gaining weight, and they smoke much more than Americans-- which speeds the metabolic process and may help refocus oral cravings away from food.

Eliza Kendall said...

Some Western Europeans also get month long vacations. And a 48 hour work week is the maximum allowed per EU. Stress seems to correlate with increased weight, though we all know how correlations may be meaningless. Also, people in European rural areas tend to weigh more - even with all of the farming and the chopping wood and such.

This makes me recall reading about SAMHSA's campaign to educate those with psych diagnoses on healthy eating and exercise due to death rates. Having taken my share of antipsychotics, no amount of organic food or weightlifting put a dent in the visceral fat I had gained. I am fortunate in that it has only been twenty pounds. Still trying to work on the back problems from the weight gain.

Looking at NIMH statistics, suicide rates are a lot smaller than death from heart disease, but the deaths do occur at a young enough age to affect the number of death and psych things as said by SAMHSA and the like in a clinically statistically significant way. Heart disease happens in midlife, suicide often happens in young adulthood (or earlier on rare occasions).

In the US atleast, I think a more useful goal would be to encourage "natural" eating and exercise-esque activity as a way of improving mood and taking some time out of the week to focus on something besides work, school, etc. Despite the weight loss difficulties (on to anticonvulsant now), I have noticed I get moody on days I'm stuck inside and eating crappy food even though it isn't the norm for me. Anecdotal evidence has reported similar feelings. And no harping. Yeesh. I find that so irritating.

It could also be more useful to remember that it is only within the last two hundred years-ish that lifespans have increased significantly. I wouldn't be surprised if more time alive means more vulnerability to health issues.

On the plus side, weight loss lectures give helper folk a sense of helping in that it is something people might be able to control and thus they have done their helping job. Not cynical, no...

Jane said...

If the doc is actually going to help the patient lose weight then he or she should say something. If not...then there is really no point. If the patient has money to spare, the doc can always make a referral for the patient to see a nutritionist. That's what Jonah Hill did. He hired a nutritionist so he could lose weight to be in 21 Jump Street and he learned how to make better food choices. It worked well because he looks very slim now.

I guess we should all make more of an attempt at following My Plate. Half of what we consume in a day should be from the fruit and veggie group.

Anonymous said...

We don't have any evidence that losing weight increases longevity? I guess....although we certainly have evidence that being obese decreases longevity. Obesity is now the 2nd modifiable cause of cancer behind tobacco abuse. I do believe that it is modifiable.

Can people be healthy and be overweight? Of course, but from a purely observational stand point, I would guess that the number of obese people that I see that are "healthy" is very small.

I do agree that is not necessarily the physician's responsibility to fix the problem. You are right. We are not/can not be there enough to monitor the situation. Like so many lifestyle issues, people need to take responsibility for their own lives.

A couple of years ago, I read a fascinating book "The End of Overeating" written by David Kessler, former FDA commissioner (he took on Big Tobacco during his tenure at the FDA). He tracks the obesity epidemic and argues that the food industry (possibly in bed with the government) has created the obesity epidemic. In a well documented book referring to numerous rodent studies (I tired a little of reading about all the poor rats and mice that were induced to become obese by alterations in rodent kibble), he argues that fat, salt and sugar can alter our brain chemistry so that we loose the satiety signal. Furthermore, the combination of those things (fat, salt and sugar) make it impossible for the brain to say no to more in many (not all).

If you track food consumption in America, as we have become obese, food has become more processed. Processed foods tend to be very high in salt, which has a tendency to induce people to eat more. If you look at the really "good" foods, they have the triad. For example, barbequed chicken wings: fat salt and sugar in the wonderful sauce. Same thing goes for big hamburgers, french fries (fat and salt with sugar added through ketchup.

I have also come to believe that artificial sweeteners, which we all consume in an effort to lose weight are just as bad as regular sugar (perhaps worse) in turning on the " I want more" cycle of eating.

As I have struggled with the weight "creep" of aging, I have been making a commitment to NOT eating out of a box. I am severely limiting processed foods. It's odd, because now I hate "good food" from a restaurant. It is way too salty for me and I feel ill afterwards. I now crave fruits, and interestingly, have been losing weight without trying (while eating more).

As a qualifier: I was an obese child, and I have struggled with weight as well as major depression throughout my adult life. With major depression refractory to medications, my lifestyle is what saves me (exercise is very important for my ability to manage my depression as well as my stress). As I have entered this journey to alter my diet, I have found that my depression seems to be abating, too. This may just be where I am in my mood cycle, but I am for once hopeful that I can keep it at bay. I have always known that food is a drug with the power to comfort. I now wonder if it has the ability to depress. A pediatrician in my town believes that the chemicals/dyes in foods are leading to the increased incidence of ADHD (I don't know if there is evidence to support that or not). Just has some of the psychiatric meds increase weight, is it such a far shot to suggest that all of the chemicals that we are putting food might not be a part of the problem as well? That becomes a very difficult thesis to prove, but from a personal experience stand point (like the previous poster, what I write here is anecdotal), I'm convinced.

This is way too long....the issue of our sedentary lifestyle can create a post which is just as long from me.

Anonymous said...

My doctor is a little pudgy. He recently told me that I needed to lose a little weight for a health reason. I loved him for it, and I started doing it. Thing is, I love him for it because he wasn't rude or intimidating in telling me about it, likely because with his slight pudginess he understands what it feels like and just how difficult it is to lose that weight; he was very straight forward, suggested it but didn't demand it, and he explained to me exactly how it would affect my health issue. Prior to, and even after, my weight didn't come up again; I wasn't nagged, I wasn't belittled or guilted, he gave me the information and left me to do with it as I pleased. As a result, if I want more help from him, I feel assured that I can ask him for it.

There's no problem with suggesting weight loss. There's a problem with demanding it, or failing to show tact when making the suggestion. My experience only made me love my doctor more, it solidified in me that I had made the right choice in doctors for me.

It's all about tact. Doctors shouldn't stop suggesting weight loss where it may help with a health issue, but they should take a good look at their approach and whether or not it's actually helping or creating a rift in the relationship.

jesse said...

Interesting comments. Is there any real evidence that physicians shame overweight patients? I have never heard such a thing.

That it may be useless to talk about it is a valid point. It has not happened yet (to my knowledge) but I would not be surprised to hear of a physician sued because he did not encourage a patient to lose weight, with recommendations for a nutritionist and weight loss program, and the patient later suffered a heart attack or needed joint replacements.

Yes, fast food is not the only culprit. The causes are complex. The next time you see news films of Americans in the fifties, though, note that their weight is very different from what is so common today.

Americans eat much more than Europeans do. Restaurants have "up sized" portions dramatically. I have been to Italy numerous times. People there, in restaurants and in their homes, eat considerably less than we do here.

jesse said...

That Anonymous post above is not too long! It is brilliant.

Anonymous said...

I have gained a lot of weight since I started taking atypicals. My pdoc does not consider it an issue. Could that be because pdoc is on the obese side while I am just overweight? Weight is an off limit topic there. maybe pdoc also takes an atypical??

Anonymous said...

My frustration was the other way around. i often felt like my psychiatrist downplayed my concerns about weight gain associated with certain meds he prescribed. i would have appreciated more attention paid to these concerns as weight gain impacts my self confidence and also affects mood. Having pants get too tight puts me in a foul mood. i guess the reason it got downplayed is that so many of the psych drugs can cause weight gain.

i have gained 10 pounds with TCA's and i don't know that i will continue on them even though they've helped lift the depression because i'm afraid that number will keep going higher. Gaining weight makes me feel bad, and i do not want to risk diabetes or metabolic syndrome, etc.

Anonymous said...

I gained almost 70 lbs from psych meds - TCAs and atypicals. I could not drop the weight despite (a continued lifetime of) healthy eating and consistent (60ish minutes of gym/swim daily) exercise. It was a tradeoff I was content with - I hate the weight but like not being acutely suicidal all the time. My regular doctor and psych had no comment because the exercise and healthy eating were already in place. It sucks that psychiatry forces me to make that choice though in this case, I'd have to say that being overweight undoubtedly increased my lifespan.

Anonymous said...

i think the problem i have is that there seems to be an assumption that weight gain should be worth it, which is true for some people but it's not true for all patients. i understand my doctor is well intentioned, but for me personally, any more weight gain and i will have to stop taking the meds. Gaining weight makes me feel bad about myself, and that is the last thing i need.

This is where i think it's really important for the doctor to listen to what side effects the patient is willing to risk because we are all different. i am not willing to trade depression for increased risk of diabetes, and he and other people may feel differently. That's ok for them, just not for me.

Dinah said...

Shame is something determined by the recipient, and I think all of society shames the obese.

I grew up in the 70's, not a good time for food: Wonder bread, twinkies, scooter pies, Miracle Whip, chef boy r dee, cap'n crunch, and recipes with jello, or the ubiquitous canned cream of mushroom soup. In high school I snuck out every day (yes, everday, at least after we could drive) with 2 friends for fast food.

People were thinner then. They live longer now.

Meds make some people gain weight. I treat plenty of people who do not gain weight. It's a risk, and I think someone who is suffering terribly should take the "risk"- they may not gain weight. But I tell people to get weighed twice a week. If someone starts gaining, only they can decide if the tradeoff of feeling better (if they even do feel better or even do gain weight). I wish we had more weight neutral options available.

We still haven't determined what is the right thing to eat and the opinions vary day by day (today, "organic" is not as healthy as thought).

We eat more, we eat super-sized servings, and school is a virtual eat-a-thon with constant events,parties, donuts for homeroom, snack after sports, bake sales...there are more restaurants, more variety, more MORE.

Okay, I have to go. I am meeting slim Jesse for burgers, fries, and drinks. This time, I don't have time to get ice cream after.

I don't find it interesting that we've gotten fat in our food-oriented world. I find it interesting that some people haven't.

pdf doc said...

We know that being overweight predisposes us to hypertension, hypercholesterolemia, heart disease, cancer, and osteoarthrtis. We also know that exercise contributes to weight loss, by appetite suppression an increased metabolic rate both during and after exercise. Exercise also affects mood through release of endorphins.

Unfortunately, many psych meds lead to weight gain.

In my practice, when I have an overweight patient, I will talk briefly with them about the risks of obesity, and will suggest some techniques to fight this, as well as recommend a weight loss program, such as a very successful one run by a local hospital. I think that this doesn't hurt, and may very well help. My (poor) memory reminds me that there was a study that showed that even brief discussion with a primary care MD had positive effects on smoking cessation and obesity.

My own situation with psychotropic meds has resulted in a 40 lb weight gain, although starting at 100 I still fit in the normal range of BMI. Unfortunately much of this weight gain is central, and affects my self esteeem. I have been bad about exercise though, coming from a background of 1-4 hours of training a day. My psychiatrist never mentions my weight; he himself is obese. I would be afraid of d/c'ing my meds for weight reasons as I am certain that they keep me out of hospital and alive!

Anonymous said...

i would probably feel the same way if 40 lbs for me meant i was still within a normal bmi but it would not be for me. i'm looking at increased risks that also affect my safety and quality of life should i become morbidly obese. i dont know, maybe i'm more concerned about it than some patients because i worked on a stroke unit and saw the impact of obesity and the things that often accompany it. i mentioned concern over not being able to button my pants, but the main issue for me really is my health and quality of life that would be impacted if i continue to gain weight. these drugs are the culprit because they're stimulating appetite.

oh how i wish i were one of those pts that did not gain weight with tca's because they've been very helpful. it sucks. finally find something that works and now this...

Anonymous said...

I go off my meds form time to time due to the weight gain. I still do wonder about my shrink, who is way heavier than I am. I would love to sk if this person is on meds that cause weight gain or if it is something else. It does kind of bug me that I feel I can never bring up the weight issue (my weight) to someone whose BMI is much greater than mine. I fear being told that my over 30 pound gain is meaningless. I guess it is if comparing to someone who is more than just "full figured". I do worry about my weight not just for the sake of vanity but because some of my blood levels are also up. My previous doc just told me to exercise and that was easy to say but it did not give any results and did not deal with zyprexa hunger. That doc was also normal weight. It made me feel like i had no will power. The current heavy doc just does not discuss weight. As a result, I do not discuss my med holidays. Note to docs: please be willing to talk about weight, talk not preach and please take us seriously even if you carry extra pounds yourself. I truly believe in the whole wounded healer thing but more in the wounded than the healer part.

Sunny CA said...

I would be for not saying anything unless the doctor has a concrete plan that has been field tested on hundreds of patients and the doctor is willing to provide the support necessary to follow the plan. The doctor ought to try following the plan himself or herself for six or ten weeks and see if the calorie count is adequate or if the dieter will feel like taking a bite out of the table leg after a few weeks. There ought to be a support group and a list of ways to follow the plan when in a hurry.

I have been dieting since I was 18 years old. At 61 I am pretty discouraged. Always I feel that if I make an extended effort at very strict food limitations, like 1000-1200 calories, I stay on for a half to a whole year by gritting my teeth through the agony of constant hunger and awful tasting meals, while watching family and friends eat normal foods in normal portions. When I finally can't stand the deprivation any longer and even have some normal meals and some diet meals, I gain. The exercise twenty minutes three times a week advice is not for folks like me. I have to hike up and down hills an hour and a half to two hours a day to hope to make any headway. It makes me spitting mad to have an overweight doctor tell me to lose weight when I already am walking two hours a day and I eat a no added oil, no added salt vegan diet. My bloodwork is terrific because I eat well. In my opinion, bloodwork and blood pressure are tied to what the patient is eating and how much the patient is exercising, not to the patient weight.

Dinah said...

No added oil, no added salt vegan diet. What is left to eat? Oh gosh, I even put salt on my celery.

Sunny CA said...

It is the Caldwell Esselstyn MD "Prevent and Reverse Heart Disease" plan. Similar to Dr. John McDougall's plan, Pritkin's plan, and Esselstyn's son, Rip Esselstyn has come out with the Engine 2 plan based on his dad's plan but a little looser. There was a movie on it last year "Forks Over Knives". It is a whole foods plant based diet, so there are veggies, fruit, beans, whole grains eaten whole, spices and herbs.

I was mulling more, and when a physician says "you are fat", there is the assumption that the patient does not know he is overweight. There is also the assumption that the patient is eating burgers and bon bons. What are the chances that the person does not know he is overweight? Most obese and overweight have tried over and over to lose and many have lost and maintained the loss for a period of time. A large percentage of overweight people are on a diet right now. A lot of overweight are thinner than they have been. Does a doctor ever ask? How do you view your weight? What do you eat? What is your exercise regime? I am far more motivated by my appearance than my health, and if I can't get thin to look good and fit better in airplane seats, then I won't lose weight so I don't get criticized by my doctor. I met a woman Saturday when I went kayaking who said she works out at the gym 3 hours a day. I talked to (an obese) woman this evening who is on a Master's swim team, trains daily, and competed in a 2 mile lake swim over the weekend. Imagine how galling it would be for these women to have a doctor tell them they arebfat and need exercise. I exercise more than all my doctors.

Alison Cummins said...

There are ways to discuss it.

If weight is causing a problem, then the doctor can discuss it in terms of the problem. "You have high blood pressure and we need to bring it down. There are different methods of doing that. One is to lose weight, and if you would like to try that I can help you. Another is blood pressure medication."

This educates the patient and leaves the choice up to them. If the patient already has a lot of experience with weight loss and control they may be ready to try medication. Someone who never bothered to try to lose weight in the past may be motivated to start.

Another is to ask, "Do you gain weight easily?" which is much less stigmatizing, and leaves more room for action, than the statement "You're fat."