Category Archives: How Doctors Should Talk to Patients About Obesity

How Doctors Should Talk to Patients About Obesity, obesity and weight control

The Skinny On Obesity

On Fridays, we have frozen pizza for dinner. My daughter, Kathryn, bakes it; my job is to cut it into slices and to do the cleanup. This has been our family tradition for years. It is a minor tradition, one with little meaning other than acknowledging that the end of the work week has arrived. Yet, it has become a repeating event in our lives.

For whatever reason I cut the pizza in half and then in inch wide strips.  I don’t know why I started this unconventional practice, but it has also become part of Friday pizza night.  That along with a glass of Crystal Light or perhaps a small glass of red wine.  It is a simple meal, predictable, and uninspired. 

I only ate two and a half strips of pizza last Friday; I wasn’t hungry.  To translate this into a measurement that most would understand, I ate less than two squares of a “delivery” pizza.  That is what I ate for dinner; that was the total amount of food that I had that evening.

The day came to a close in its usual way.  I flossed and brushed my teeth, took a shower, and changed into my sleepwear.  Laying in bed, I became aware that I was feeling guilty, guilty that I had overeaten on pizza.  I was ashamed that I had eaten two squares of pizza.  These feelings were coming from somewhere deep inside of me, a place of emotion rather than logic.  My logical brain knew that eating two squares of pizza was hardly being gluttonous.  Yet, my emotional self felt otherwise.  “How curious,”  I thought to myself.  “What distorted feelings. I should write about it.”  And so I sit in my small study with its mullioned windows and type, not really knowing where this post will lead but understanding that it will take me somewhere.

The other day, I was talking to my sister-in-law, who is a former educator.  Like many of us, she has struggled with her weight despite carefully watching what she eats and going to the gym on a regular basis.  She is now trying an expensive packaged diet that consists of tiny protein bars, shakes, and a spartan mini-dinner. She has lost some weight on this program, but it is not magic.  Her total daily caloric intake is between 800-1000 calories, which is a starvation diet.  These ultra-low calorie plans fail in the long run as they throw one’s body into starvation mode; when the dieter returns to normal eating they quickly gain their weight back.  Many years ago, one of my 100-pound weight losses was on a similar diet.  I reached my goal weight and was given a food maintenance plan. I’m 6’3”, and I should be able to maintain my weight on almost 2800 calories a day, but my diet counselor wanted me to eat 1200 calories a day for the rest of my life.  How long do you think I was able to sustain that?  Yes, you are right.

Earlier, I had visited my sister and was delighted that my adult niece was there.  Like many in my family, she has weight concerns.  She has tried extraordinary things to control her weight.  However, to know her fully, you need to look beyond this one tiny fact.  My niece is highly educated and holds several graduate degrees from prestigious universities.  She has worked in the banking industry for decades, and her professional acumen is highly regarded.  She is a mother and a stepmother.  She is passionate about the environment.  She is a kind and good person. Why can’t this smart, accomplished, and sophisticated person lose weight? That should be simple, right?

The two of us talked, and we soon drifted into a discussion about our struggles with food. A discussion whose information has morphed over the last few years.  Although I still carry the emotional shame of having a problem with my weight, I also have a better understanding of the complexity of this disorder.  

I acknowledge that I have a problem with sugar.  Frankly, I would say that my behavior around that white crystal mimics an addiction.  I would rather eat high sugar foods than just about anything else.  Seven or eight years ago, I gave up all concentrated forms of sugar and continued practicing that behavior for many years. COVID isolation happened and I treated my stress by allowing myself a small sweet treat every day.  Over time, my sugar load increased, and soon, I was back to my old ways. My return to sugar was no different than an alcoholic’s return to alcohol.  It was a relapse.

This January, I recommitted to a more balanced life with a twist.  Once again, I stopped eating concentrated forms of sugar, but now allowed its consumption on special occasions, like Christmas or a birthday.  I made this change to see if such a practice would be more sustainable.  Most who know me would say that I have a will of steel, but steel can rust and weaken.  Willpower only goes so far; I needed to be adaptive because sugar seems to impact me differently than the typical person. I see other people effortlessly passing on desserts. For me it is a herculean effort.  It is clear that my brain’s response to that sweet substance is different from others. Why is that?

I spent much of my professional life as an expert in addictions and I have treated thousands of alcoholics and drug addicts. Many who sought my help desperately wanted to stop their substance. They knew it was destroying their lives. It was not providing the benefits that it once did. Yet, they could not stop.

I occasionally drink alcohol. However, I have a very different reaction to it than they did. I can enjoy a single drink, but often a second drink starts to taste bitter and unpleasant to me. It is usual for me to get half-way through a beer or a glass of wine and to give the rest to my wife to drink. Stopping is not a conscience decision on my part and involves zero willpower; my alcohol consumption is being automatically regulated by my body. This is completely contrary to my desire to consume sugar, but it gives me some insight in how some “normals” may react to food.

Many years ago, I sought help from a young dietician/diet advisor.  At that time, I was significantly heavier than I currently am and could barely walk up a flight of stairs without becoming winded.  Her plan was to have me vigorously exercise for 90 minutes a day and then add another 90 minutes a day of “casual” exercise, which she defined as speed walking or jogging.  I’m sure she found such activity personally rewarding, but she had no clue as to my ability or willingness to embark on such a draconian practice. Oh, and I was working 60 hours a week at that time.  All I needed to do was to find another 3 hours of free time every day to do something that I couldn’t possibly succeed at. Her plan demoralized me.

I recently compiled my weight loss history, which started when I was in 7th grade.  It shocked me to realize that I had lost 100 pounds or more on at least six separate occasions in my life.  In addition, I have lost smaller amounts of weight countless times.  It upset me to realize how many potions, procedures, diet consultants, prescription medications, support groups, fasts, and crazy diets I have endured while trying to lose weight. I have spent thousands of dollars on programs ranging from Seatle Sutton to Nutrisystem.  I always felt that my inability to maintain an average weight was a personal failure.  This was despite the documented fact that at least 95% of all diets fail, and the percentage is likely greater for those, like myself, who deal with chronic obesity.  Imagine if a teacher was teaching a class where 95% of the students didn’t pass, and the administration blamed the students rather than the teacher. However, it is usual to blame the fat person. Does that make any sense?

I found that my battle with weight prevented me from seeking proper medical attention, as I felt ashamed that I was a fat doctor. Shouldn’t I be a model of health, I had the best knowledge and training?  Several years ago, I wrote a letter to my primary care doctor confessing my reluctance to see him.  He was more than understanding, and I freed myself of this irrational fear by remembering the OA motto, “You are as sick as your secrets.”  Once I revealed my secret shame, my PCP became my ally instead of my imaginary judge.

Tom, a close friend of mine and a successful businessman, battles obesity.  He has type II diabetes and was started on the GIP/GLP-1 agonist, Mounjaro, for that condition.  Mounjaro, along with Ozempic, have been in the news due to their impact on weight loss.  My friend, who prior would constantly think about food, effortlessly lost over 40 pounds.  It was shocking for him to move from a position where he was always hungry to a place where he could pass on lunch because he was still satisfied from breakfast. 

My friend, Barb, is an intelligent and committed person who always looks her best. She is dedicated and focused.  Barb has struggled with her weight her entire life. Yet, she is always exploring healthy eating options and exercises on a very regular basis. Despite her efforts, the weight stayed on.  That changed when she started on Ozempic and suddenly she was able to lose a significant amount of weight fairly effortlessly.  It was a miracle for her.

For both Tom and Barb a couple hormones were adjusted, and they were able gain control over food without thinking about it. It just became a natural process.  I believe their experience draws into question the whole “lack of willpower” explanation of obesity.  Imagine blaming a person with diabetes for having a lack of willpower.  Instead, we treat their medical condition.  We should do the same for obesity.

In popular belief, fatness is due to a lack of discipline, and it can be considered a sin in some religions. “Just eat less.”  “Push the plate away.”  “Exercise more.”  “Don’t be a lazy pig.”  Such naive and ill-informed statements have little basis in truth, yet they are supported not only by the general population but also by many in the health community.

Hunger and appetite are automatically regulated, just like breathing and heart rate.  Some people eat what they want and maintain an average weight. If they indulge in a treat, their body automatically reduces what they eat later in the day.  That is not the case for many obese individuals. Often, the message from their brain is to eat more and more. In my case, it was to eat more and more sugar.

There have always been overweight and obese people, but the numbers have gone from a minority to over 71% of the US adult population.  Childhood obesity is now considered a significant health issue.  One in eight adults worldwide (per WHO) is considered obese, and weight issues are becoming a concern in countries like India and China, where starvation has been a problem in the recent past.

As we gain a better understanding of body weight, it is clear that obesity is not due to laziness or gluttony. It is a complex medical condition that involves a multitude of factors, including genetics, epigenetics, psychological state,  social influences, food availability, food marketing, hormonal dysregulation, environmental factors, and even the gut biome.  Researchers are becoming aware of the role of ultra-processed foods that are said to be engineered to be “addictive” to consumers, as well as the outright lies promoted by food industries that paid researchers to push their agendas. 

As our Western diet has infiltrated other cultures, so has obesity.  On some level, there must be a correlation.  Yet, instead of looking at these factors, it is still easier to blame the individual, which makes no sense. Smoking causes cancer, and we have known that for many decades.  Smokers were blamed for using this addictive substance because it was “their choice.”  Eventually, governments pointed the finger at tobacco companies who promoted children to start a life of addiction by romanticizing smoking, offering enticing prizes for cigarette wrappers, and promoting smoking as “adult” and “cool.”  If you could get someone to smoke as an early teen, you created a customer for life.  Admittedly, a shortened life.

It is difficult to know where obesity shaming started, but it continues to be one of the few socially acceptable areas where public ridicule is even encouraged. There is a connection between religion and “the sin of gluttony.” A position based on ancient cultural biases rather than scientific evidence.  Additionally, groups tend to ostracize anyone who is different from the norm.  This may be related to survival instincts, economic factors, and even fashion trends. 

People of color have been demonized as being immoral and lazy, women were labeled as being too stupid to vote, and members of the LGBT community have been falsely accused of trying to corrupt the young. Marginalizing these groups offered the majority group power, status, and economic benefits.  But what about fat people?

That is a complex question, but one can’t deny the billions of dollars spent on diet programs, diet books, diet foods, and diet drinks.  Yet, it is understood by anyone who cares to look at these options that they don’t work.  I already noted how diet programs don’t work, but the same could be said of diet foods.  Who really believes that eating a 300 calorie frozen dinner every day could be a long term solution for weight management? There are now a myriad of artificially sweetened drinks on the market that are subtly or directly sold as weight loss products.  Yet, people are becoming fatter.  Research points to the fact that once our tongues detect artificial sweeteners, insulin is triggered, which can cause overeating as a compensatory measure. Fast foods, like hamburger buns and french fries, often have unnecessary sugar added and then are over-salted to compensate for that sweetness.  Our brains like sugar and subconsciously seek it when available.  Fast food can be made healthier, but the excess sugar makes it more desirable. The reality is that diet programs, food manufacturers, and food providers are in business to make money.  The more that they sell, the more profit they make.

I’m not promoting obesity as it is connected with a variety of severe health consequences from cardiovascular disease, to cancer, to dementia.  However, I am promoting tolerance, compassion, and understanding.  I would also like to highlight those things in our environment that contribute to obesity and how they need to be addressed. 

Additionally, archaic ideas must be abandoned, and just as with the tobacco industry, we need to seriously look at the research and take action on sectors that profit from making people unhealthy.  I guarantee that this will not be easy, as any time the government tries to take any step that impacts corporate profit, it is fought by the industry that is affected.  Most can remember those tobacco CEOs standing before Congress and swearing under oath that smoking was not hazardous to health when they clearly knew that it was. There are many other examples that range from companies fighting nutritional labeling on packaging to battles against removing trans fats in foods, an unnecessary additive that has been proven to increase heart attacks, strokes, and diabetes. 

There have always been weight loss drugs on the market. Most sensible individuals realize that over-the-counter potions are useless. However, the majority of prescription weight loss medications only offered marginal help.  That is until GLP-1 agonists like Ozempic and Mounjurno (GIP/GLP-1) hit the market. These medications do have some risks, but they are typically well tolerated, and they offer statistically significant weight loss.  More importantly, they demonstrate that for many people, obesity has little to do with the “sin” of gluttony.  If GLP-1 agonists can normalize eating patterns biochemically, the converse must also be true; dysregulation of hormones contributes to obesity. These medications give vulnerable obese individuals some of the same controls afforded to ordinary weight people.  For many, they are life-changing.

Yet, most insurance companies will not pay for these proven treatments despite the reality that normalizing their client’s weight would save them money in the long run. Additionally, Medicare is forbidden to pay for anti-obesity drugs.  Obesity is related to the expensive treatment of illnesses from heart disease to cancer.  Insurance companies’ refusal to pay for proven obesity treatments is likely due to short term goals for profit.  A health insurance company may be siloed into multiple divisions, such as inpatient care, outpatient care, pharmacy, and others. The pharmacy division may be judged by its ability to reduce costs regardless of the financial impact that such reductions have on other divisions in the company. 

We have all been told the lie that obesity is simply caused by too many calories in vs too few calories out. This “illusory truth effect” has permeated not only the general population, but also the medical community.  Of course calories count, but the question should be, “Why are people eating too many calories?”  I touched on some of the reasons above.  However, many of them are never addressed as it is always easier to blame the victim.

With any medical condition it is important to treat a patient holistically.  All patients benefit from a healthy diet, stress reduction, appropriate exercise, and adequate sleep.  However, for many overweight and obese individuals this is not enough and medication intervention is necessary. 

Being fat is no longer a minority position in the US, as the majority of its population qualifies.  This, plus updated research, is likely the reason that there is some loosening of anti-fat folkways and mores.  Shame and blame need to give way to re-education and acceptance.  The food industry must be more accountable, and our government has to stop placing all of the responsibility on obese citizens, and must offer more realistic options to combat this epidemic. For the first time, we have effective medications that can treat obesity, which now adds $200 billion dollars to yearly US medical costs and contributes to some of our most serious medical conditions.  To put this in perspective, the national cost burden for cancer in the US was around $190 billion dollars in 2015. Think of the billions of dollars spent on research and treatment for illnesses like cancer, diabetes, and dementia. No one blames people for becoming diabetic or demented.  No one blames cancer victims. They get sympathy, support, and appropriate treatment.  The same needs to be extended to the 71% of our population who now deal with weight issues.  To think otherwise, or to make misguided moral judgments will cost everyone more in the future.

Lastly, there are those who embrace  their plus-size bodies.  They should have the right to be who they are.  Judging someone on a single characteristic says more about the person who is judging.

Peace

Mike

Sitting in my study, writing this post.
achieving life goals, Caregiving Help, How Doctors Should Talk to Patients About Obesity, kindness, Making Change, Motivating Chage, psychology

How Doctors Should Talk To Patients About Obesity, An Open Letter To Doctors

Last week I had surgery, a long surgery that required over an hour of operating room time, but the operation was not my greatest fear as I approached this process.

What concerned me the most? I feared having to get a pre-op clearance from my internist; a simple visit that would require less than 10 minutes of contact time. You may be thinking that my primary care physician is mean, rude, and evil. Of course, this is not the case. He appears to be a nice man and a good doctor. If I felt otherwise, I would not work with him.

So Dr. Mike, what is the problem? First a little more background information.

As a person who has battled obesity all of my life, I have become acutely aware of the stigma that comes with weighing excess pounds. Few human attributes can be ridiculed and condemned in the millennial “microaggression” culture of 2018. Imagine criticizing or mocking someone because of their race, sex, religion, sexual preference, gender identity, physical stature, or a multitude of other differentiating human characteristics.

Making fun of “fat people,” is an acceptable national sport, even though the CDC reports that over 70% of adults in the US are now overweight. Of course, as the overweight population explosion redefines the concept of what is normal weight, there will always be those outliers who exist beyond a standard deviation from that norm. There will always be a group to abuse with fat jokes, both overt and covert criticism, and outright disdain. If you are obese, it appears that it is OK for others to assume that you are lazy, dirty, and stupid.

We would never make such assumptions for other medical epidemics. Imagine someone undervaluing you because of your high blood pressure, or your fasting blood sugar? Just like obesity, these illness are caused by multiple factors: genetic, environmental, and lifestyle. Unlike obesity, there are good medical treatments for these ailments, making them easier to treat. The majority of folks with high blood pressure can significantly reduce health risks with medication management alone. However, the majority of obese people will continue to be fat despite diet plans, medications, exercise, and shaming television shows.

I lost over 100 pounds about 3 years ago. I did this after failing many traditional techniques of weight loss. I feel that my weight loss was indeed a miracle that was fueled by common sense, rather than modern medicine.

We are humans, not machines. We are motivated and influenced by a multitude of factors. This variability can be considered a weakness, but it should also be acknowledged as one of our greatest strengths. We are complicated, and as such simple blanket solutions have marginal utility.

Over the three years since I lost weight, I have regained a small percentage of my weight. Most people have told me that I look better with a few extra pounds. They say I look less gaunt, and more vital with this increase. Additionally, I have long shifted from judging myself based on a number on a scale. My lifestyle changes have been just that, they are not strategies to lose weight and thereby achieve some sort of false utopia. “My life will be good if I am not fat.”

Three years into this process:

I still can wear my same wardrobe.
I still exercise every day, walking from 3.5 to 8 miles.
I still avoid all forms of concentrated sugar.
I still practice healthy eating.
I still make an effort to eat more natural foods.
I still assess and correct hidden forms of weight gain, like emotional eating.

When I determine my current status I would say that my efforts continue to be successful, but what about the matter of my small weight gain, does this one objective parameter signify failure? I would say, “No.”

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I sit in a chair opposite from my primary care doctor who is staring at a computer screen.

“You have gained weight.” My doctor says. My initial impulse is to apologize for my failing. I resist. My second impulse is to defend my position. I resist and remain silent. “Are you exercising?” I reply that I am and had already walked four miles before our appointment. “But what about cardiovascular exercise?” He retorts. And so it went. Three minutes of questioning that felt like three hours of interrogation. Pain always feels worse when inflicted on an open wound.

***********

Dear readers, I’m am a resilient person. Besides, I am good at using the counterbalance of logic when dealing with my emotional exaggerations. However, there is more to this story than just a detailed account of me stepping on the scale and my emotional response to that event.

Being a physician, I understand the power that doctors have over their patients. Patients come to us in an extremely vulnerable state looking for help. Studies have shown that a statement like, “You need to quit smoking,” will convert some active smokers into former smokers. Unfortunately, in medicine one size does not fit all. It is easy for physicians to generalize the above truth and think that simple pronouncements can be used to motivate all lifestyle change. However, a doctor’s command is a partial solution at best, and should only be used when wielded within a broader understanding of what causes people to change.

Many of the illnesses that physicians treat on a daily basis have a strong lifestyle component. My weight loss eliminated my need for blood pressure tablets, high cholesterol medication, and a CPAP machine. So why is it that physicals don’t learn and employ simple motivational techniques so they can move their patients towards health? I don’t ascribe to know all of the answers to this questions. However, I do know some of them.

Physicians in the US work in a production model. We get paid by the volume of the work that we do. See fewer patients, make less money. As medical practices get bought up by business investors the push for physicians to do more continues to increase. A good business model consists of finding ways to spend less and make more. This fact is contrasted by a simple truth; we are caregivers, and most of us want to provide care.

Our contact with patients is reduced by the use of physician extenders. Someone else takes our patient’s blood pressure and obtains their chief complaint. We employ electronic medical records (EMRs), which provide a clear notation of our treatment plan, but does so at the cost of patient interaction. Patients now have the “privilege” of answering our questions as our eyes are focused on a computer screen instead of them. Patients want care from us, and we want to meet their needs. There is a pill for everything, and today’s EMR makes prescribing absurdly easy. Is writing prescriptions the same as providing care? I believe that it is only a part of our job, and it should not define us in total.

When I retired from private practice, I was fortunate to have patients write goodbye letters to me. Almost universally they said that they valued their time with me because I listened to them, didn’t judge them, and guided rather than controlled them. To do these things I needed to spend time with them. I would have made more money if I saw 6 people in an hour, rather than the two that I scheduled. However, I would not have known my patients as well, and more importantly, they would not have known me as well. Trust is a function of integrity multiplied by time. Trust by itself offers a positive corollary to patient satisfaction and well-being. Besides, a career that includes connecting with others is eminently more satisfying to we providers than one that does not. A win/win.

One factor needed to motivate change is time. Unfortunately, extending the length of appointments may not be possible in today’s corporate medicine climate. There are indeed a variety of stop-gap strategies that doctors can do to build a connection, such as deliberately spending a few minutes directly with the patient before turning to a computer screen. Such simple changes can make a patient feel more connected, but they still don’t address the elephant in the room.

How should doctors interact with patients to create change? Fat people know that they are overweight, and should lose weight. Alcoholics know that they drink too much, and should stop. Diabetics realize the importance of blood sugar control, and that they shouldn’t eat that extra donut. We live in a culture that shames, and it is likely that some will avoid being humiliated by their physician by avoiding seeking necessary medical care. I admit that I have been an avoider in the past.

Big problems become smaller when shared with someone. I am willing to tackle projects that I would not usually attempt when I have someone at my side. This phenomenon is even more evident if that “someone” has expertise that I lack. If you have been reading my prior post, you know that I have been converting a cargo van into a camper. I dare to significantly modify my van because I am doing the project with a friend who has expertise far beyond mine in such manners. We, physicians, have expertise far beyond our patients in such manners as health. Most reasonable patients accept this, despite the advent of the Internet. A colleague of mine has a cup in his office that reads, “Please don’t confuse my medical degree with your Google search.” However, most patient’s intrinsically understand our expertise, which is why they are seeing us.

Doctors need to connect with their patients as human being to human being, and they need to do this on a level that patients can relate to. We need to become trusted knowledgeable friends rather than overbearing, critical parents.

We need to understand where our patients are coming from, and how willing they are to make change. We need to problem solve with them. Imagine if my doctor asked me, “Are there any barriers that prevent you from seeking medical attention?” Or, “Are there any ways that I can help you with your lifestyle change?” Those simple questions would instantly change my relationship with my care provider. I would want to meet with him, and I would look at setbacks as problems to be solved, rather than justifications for criticism.

Once a patient’s cards are on the table, all things are possible. Is the doctor’s goal the same as the patient’s? What are the barriers to achieving the desired goal? What steps should be tried? How will progress be measured? How is a reversal of progress addressed? Empathy joins, criticism divides.

A meaningful connection with a patient doesn’t happen all at once. Relationships develop over time. However, imagine helping your patients make a significant and real change. Imagine the satisfaction of having a substantial connection with them. What would it be like to work with real people instead of being a reviewer of lab data? What would it be like to end your workday with the knowledge that you truly connected with someone in a meaningful and significant way that changed their life? What would it be like to move from treating diseases to treating people?

We blame our patients for their failings, while we steadfastly hold on to methods and techniques that simply do not work. Imagine if our relationships with our patients were more as a knowledgeable and caring peer rather than a stern and critical parent? Imagine yourself as the patient. You are aware that you have a problem and you need help. Who are you going to ask? Someone who tells you what you already know, makes you feel bad, and offers no real help? Probably not.

Patient Mike