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Wednesday Aug 31, 2016

Help Patients Conquer Obesity With Education, Empathy -- Not Shame

"You need to lose weight."

"You are obese."

"Time for a diet."

As physicians, many of us have been on both the giving and receiving ends of advice about weight. But are blunt comments like these helpful in creating healthy life choices? Twitter users from around the world recently shared comments about their negative experiences related to being overweight using the hashtag #FatSideStories. Their short tales revealed that insulting people because they are overweight continues, and unfortunately, it often happens in physicians' examination rooms.

Obesity is a major contributor to a host of preventable diseases, and two-thirds of U.S. adults are categorized as overweight or obese. However, the way we measure and label obesity could use a makeover.

The standard in determining obesity to date has been the use of body mass index (BMI), a formula involving a patient's height and weight. But this flawed calculation does not always accurately reflect a person's level of fitness. There are many instances in which people may have a low BMI but are not embracing healthy lifestyles. Similarly, someone may be labeled as obese based solely on his or her BMI when, in reality, he or she has a high muscle content compared to body fat percentage.

The role of a family doctor is not to shame patients who are obese into becoming skinny. Our role is to encourage, motivate and walk together with our patients as we promote healthier life choices and embrace a balanced lifestyle. I often try to point out the correlation between their ailments and what I call their "health balance" -- that is, the relative balance between mind, body and spirit -- because there is frequently a disconnect between mind-body relationships.

Our society does a poor job of setting the bar when it comes to lifestyle. We see heavily "Photoshopped" celebrities in advertisements, too-skinny models walking fashion show runways and even new moms posting on Facebook that they are back in their size 2 jeans just a few weeks postpartum. The pressure to fit an unrealistic image can weigh heavily on a person.  

I recently met a young lady who was slightly overweight, and she was adamant about eating only once a day to lose weight. We spent a long time discussing the fact that foods are fuel, and quality nutrition creates an optimal environment for a stronger body.

I tell my patients that depriving themselves of essential nutrients and calories is not the best way to sustain a healthy balance. Sure, eating 900 calories a day will cause you to lose weight quickly, but you will be miserable and lack energy. Our bodies need fuel to work efficiently and effectively.  

On the other end of the spectrum, Economic Research Service data suggest that average daily calorie intake increased by 24.5 percent, or about 530 calories, between 1970 and 2000. Meanwhile, a CDC survey from 1999-2000 noted that the average American man consumed about 2,400 calories per day. Not bad on the face of it, perhaps, but half of those calories were from carbohydrates and processed foods.  

There is a saying in the fitness community: "Abs are made in the kitchen." I like to say, rather, that a balanced life begins in the kitchen. Living life with intention creates more balance. This goes for our food choices, as well. Of course, not everyone has direct access to healthy food. As a matter of fact, people in our most at-need communities often experience a dearth of healthy food. These food deserts pose a public health problem because fast food restaurants and processed foods provide cheaper but unhealthy options for our patients with limited incomes and limited choices.

As a physician, it is important to recognize that weight is certainly an important aspect of health, but it isn't the only one that can motivate patients to make meaningful change. That fact needs to be acknowledged, and then a team-based approach to addressing health management can ensue. The AAFP has resources that can help both practices and patients address issues related to exercise, nutrition and weight.

It's good to start by recognizing that eating is not simply intake and output. We all have a relationship with food. Some people see food as a reward. Some view it as a stress reliever. Others may use food for comfort. The connection between food and emotions can be healthy or detrimental. Understanding one's perception of food and how we may use food as an emotional respite is integral in adjusting lifestyle choices. This is made evident not only in one's weight but, more importantly, by asking introspective questions.

"How do I feel about my self-image?"

"How is my level of energy on a daily basis?"

"Do I feel strong?"

"Am I in pain regularly?"

"How much personal time a day do I devote for self-restoration?"

As we ask ourselves these questions, we might find that we devote little productive time to self-renewal. Exercise reflects the concept of renewing oneself, but other practices also can contribute to such balance. Mindfulness, eating to live rather than living to eat, developing interests outside of work that involve movement and creative pastimes also fall into this category. All of these activities reduce cortisol levels and actually contribute to less insulin resistance by reducing stress within the body.

Promoting an active lifestyle is integral in creating health. Exercise does not have to happen in a gym. As a matter of fact, doing even 15 minutes of moderate physical activity a day can lead to positive change. It is well known that exercise increases oxygenation to the brain and boosts endorphin production, which reduces stress and anxiety. Functional activities such as hiking and bicycling help reduce the risk of self-injury and pain.  

With so many electronics and stimulus in our lives, it can be difficult to quiet one's thoughts. However, studies support the importance of daily meditation to improve health. There is evolving literature that supports the importance of stress reduction and improved health. Now we are finding that regular meditation, or similar practices, reduce the destruction of telomeres, which are thought to be integral in the aging process. Similarly, being in nature or stimulating the creative centers of the brain have lasting effects on health.  

I encourage my colleagues to think about these concepts before having "the talk" with an overweight patient. Maybe we, as physicians, should try some of these concepts ourselves and see if we can create better balance in our own lives.

Marie-Elizabeth Ramas, M.D., is the new physician member of the AAFP Board of Directors.

Comments:

Dr. Ramas is correct. Obesity is every bit a marker of well-being, self-image, and situations dating back to birth or before. Education is the answer along with improvement in other social determinants with lessening of disparities and other areas that divide our nation. As an editor for Rural and Remote Health, it was obvious that obesity stalked populations with the most disparities in the most dimensions - indigenous, lower income, minority, rural, less educated, more stressed... Obesity is every bit the marker of societal dysfunction as seen in infant mortality, maternal mortality, longevity, premature deaths... Resolving obesity as with others mentioned is about achieving better balance across US populations. Worse for decades is destroying people, their health, and our nation.

Posted by Robert C. Bowman, M.D. on September 09, 2016 at 01:08 AM CDT #

Thank you Dr. Ramas for this excellent topic. I am a family doctor, but have spent the last 13 years treating obesity. It is a disease like any other - diabetes, hypertension, hyperlipidemia. It responds well to multi-component interventions including intensive lifestyle intervention, pharmacotherapy and even surgery.

However, as a family doctor I felt ill-equipped to deal with obesity. On my recertification exam for ABFM this year, there were zero questions (of 650) on obesity.

With proper training and attention, family doctors can do a great job improving this disease.

That's why I decided to get extra training in obesity treatment.

The American Board of Obesity Medicine (ABOM) certifies physicians looking to bridge this gap. National studies have shown that obesity counseling rates remain low among health care professionals. The reasons vary and include time restraints during a busy practice, lack of effective treatment options and practical tools, low confidence or insufficient training in weight management skills and counseling, or concern that raising the topic will be interpreted by the patient as being insensitive. These data suggest that there is an extensive gap between recommended obesity care and current physician practice. To address this need, an increasing number of physicians are devoting a portion of their practice to obesity care. The ABOM administers the Certification Examination for Obesity Medicine Physicians once per year with the guidance of the National Board of Medical Examiners (NBME). Family physicians continue to make up about one third of ABOM diplomates and candidates.

AAFP is a partner organization of ABOM.

Posted by Ethan Lazarus on November 22, 2016 at 10:04 PM CST #

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