By Ramsey Dallal, MD, FACS
The public’s appreciation of the dangers of obesity may have expanded recently, but unfortunately, Americans’ waistlines have continued to expand, too. In fact, a new study released in September forecasts that 44 percent of American adults living in 50 states will be obese by 2030, if obesity rates continue on their current trajectories. That’s nearly one out of two Americans. And in 13 states, the study projected potential obesity rates that could exceed 60 percent.
Imagine the havoc that could wreak on personal health and the nation’s collective healthcare budget, with the related spike in hypertension, diabetes, heart disease, stroke and the myriad other problems linked to obesity.
With the season of gluttony upon us, as we brace for holiday celebrations and the endless temptations to overeat, it seems appropriate to focus on what I see as part of the problem: the obstacles facing primary care physicians that may keep them from confronting patients about their weight.
As a bariatric surgeon, I treat obese individuals every day, most of whom have tried and failed to lose weight through conventional diet and exercise programs. What I find revealing is that an overwhelming majority of my patients comes to see me of his or her own accord: few are referred by a family doctor. Most primary care providers avoid the elephant in the room while treating their patients for health problems either created by or exacerbated by their excessive weight.
There are many reasons family physicians work around obesity rather than help patients focus on the underlying cause of their poor health. To begin with, some medical schools only recently have begun including issues of obesity and weight control in their curriculum. Many family doctors don’t have the education, training, tools or experience to adequately address the issue, which is much more complicated than simply suggesting a patient go on a diet or ramp up their exercise. So they schedule laboratory tests and sleep studies and other diagnostic procedures or write endless prescriptions to treat weight related medical problems. Prescription weight loss medications (or even questionable over-the-counter drugs) have not been used as frequently due to safety concerns (Fen-Phen, which was implicated in heart valve damage, and Meridia, which has been pulled from the market due to heart complications, have made people wary of taking new pills.)
These doctors are not being callous or indifferent. Primary care physicians just don’t have the time to initiate a long discussion about a touchy subject, or even know how to broach it so that a patient, who’s no doubt been belittled and shamed about his or her weight, doesn’t just get defensive and angry. Most importantly, and most incredibly, doctors don’t get reimbursed significantly for an “obesity” visit. Many medical insurers don’t classify obesity as a disease, so they don’t pay for a visit. What physician can afford to provide gratis preventive treatment, when they’re already in a frenzy to meet insurance-mandated time limits for ailments that are reimbursable?
The medical community is deeply divided over the issue of classifying obesity as a disease. The American Medical Association has tabled the discussion for the time being, declaring that additional research is necessary before a decision can be made. Some physicians believe obesity is only a risk factor, and that labeling it a disease would stigmatize a large part of the population, some of whom are healthy.
The physicians who want to classify obesity as a disease, and I count myself among them, believe there are genetic factors and metabolic or hormonal or other disorders that predispose some people to obesity; perhaps, for instance, they expend less calories than others who eat the same amount and do the identical amount of exercise. The propensity towards obesity is quite a disadvantage in a culture in which high-caloric foods are served in gargantuan proportions. And once an individual gains weight, complex physiological changes conspire to put the weight back on, as everyone who’s ever been on a diet has experienced firsthand.
Then, too, there’s the personal factor. Doctors, let’s face it, are the same as the rest of us. Some of them are overweight themselves and don’t have the motivation – or, for that matter, the credibility – to confront their patients.
Classifying obesity as a disease would resolve a few of these problems. It would destigmatize the issue and perhaps encourage patients to get help without feeling shame. It would mandate that medical students study obesity and learn how to understand, treat and prevent it. And it would require medical insurers to pay for obesity visits, all of which would encourage doctors to address the problem head-on.
I would give the following advice to the family physician seeing an obese patient. Try not to be judgmental. Approach the patient with compassion and understanding. Be honest in counseling the patient about the difficulty and commitment necessary to achieve weight loss goals. Teach your patient how to read labels – focusing on serving sizes and calorie count. Teach your patients to NEVER drink calories. Have them come to the office frequently for weight checks to keep them accountable.
Do not overemphasize the role of exercise – not eating that bagel with cream cheese is a lot easier than running for an hour. Encourage the patient to join Weight Watchers or other organizations that are better than physician practices at creating a network of support to assist in weight control. However, these weight loss programs should not eliminate your role as an advocate for your patient’s health. Educate yourself by understanding nutrition, so that you can differentiate science from fad. And, of course, prevention is the key. Once weight is gained, it will be difficult to lose. Lastly – set an example yourself by living a healthy lifestyle!
Obesity is a catastrophic public health issue that threatens to cripple and bankrupt the medical system. Attitudes, education and treatment need to change if we’re going to halt and reverse the course we’re on. We can’t allow trajectories to increase to the point that one out of two Americans – or more – is obese. The obstacles facing primary care physicians need to be removed so they can be enlisted in the battle for their patients’, and our nation’s, health.
Ramsey Dallal, MD, FACS, is Chief of General Surgery and Section Head, MIS/Bariatric Surgery, at Albert Einstein Healthcare Network.
As a nearly lifelong, truly obese person, I have to question the rather insouciant cure-all attitude of the medical community in promoting bariatric surgery. The long-term outcome is not rosy and according to the Journal of Endocrinology & Metabolism, life expectancy is only modestly increased by RYGB and BG surgery. Further, some 65% of these patients will be under the knife again to repair or correct complications of the surgery.
Where is the BRAIN in all of this? Responsible bariatric clinics — and I’m sure your practice is such — require extensive psychological evaluation and the demonstration on the part of the patient that s/he can follow a food plan for some months before surgery. If an individual truly desires to lose weight via surgery, s/he must adhere to a fairly restrictive plan of eating for the rest of her/his life. Where do the cravings go? Where does the obsession that led to obesity go?
It doesn’t. It can’t. According to myriad studies, and most recently the publication for professionals of FOOD AND ADDICTION, edited by Kelly D. Brownwell & Mark S. Gold, and Pam Peeke’s THE HUNGER FIX, which is the first holistic (focusing equally on mind, mouth and muscle) consumer-friendly approach to the subject, substance abuse researchers say that the brain adaptions that result from regularly eating foods that layer salt, fat, and sweet flavors (proven to increase consumption) are likely to be more difficult to change than those from cocaine or alcohol because they involve many more neural pathways. Almost 90 percent of the doparmine receptors in the vental tegmental area of the brain are activated in response to food cues.
Further research also shows direct evidence of lasting and fundamental injuries to a part of the brain that helps us regulate our food intake, the hypothalamic arcuate nucleus. Within three days of being placed on a high-fat diet, a rat’s hypothalamus shows increased inflammation; within a week, researchers see evidence of permanent scarring and neuron injury in an area of the brain crucial for weight control. Brain scans of obese men and women show this exact pattern as well.
What is left without food when the dopamine and serotonin transmitters have been ravaged by addiction? A dry drunk — a rage-aholic — recidivism — addiction to a new substance (alcoholism is on the rise among bariatric patients) — or, if the patient is lucky, membership in a strong support group that focuses on learning how to live for the first time or a program such as Peeke suggests of foods, exercise and the practice of positivity to regenerate the VAT.
Surgeons can be amazingly sensitive and protective of their patients, but they are not trained to see the big picture. Until the AMA begins to look at obesity and overweight as many modern trends and hurdles converging, it will continue on its way to epidemic proportions with the risk equally good of crippling patients through surgery as through having done nothing at all.