"Obesity stands in the ignominious position of being the only epidemic in the latter decades of the twentieth century and into the new millennium that nurses - clinicians, academicians, and investigators alike seem to have virtually ignored."
- K.E. Dennis, Nursing Clinics of North America (4)
Most surveys consistently find that doctors, in the primary care setting, don't regularly advise their patients on the basic principles of exercise and nutrition. It should be no surprise, then, to also find that doctors are even more reluctant to medically treat the overweight patient for the underlying lifestyles that have brought about their medical problems. In one notable study (5), a group of 633 patient-doctor visits were observed and recorded. Of the patients making these doctor visits, 68% of adults and 35% of children were overweight, a group fairly consistent with the national statistics. Excess weight was mentioned in only 17% of encounters. Weight loss counseling occurred with 11% of overweight adults and 8% of overweight children. These statistics are sad and speak strongly to the growing incidence and problems of obesity in this country.
Physicians remain, for most patients, the most trusted source for health information and can make the greatest impact on the lives of their overweight patients with simple exercise and diet "prescriptions." However, doctors have all too often failed their patients when it comes to directing their patients to live healthier lives. (1,5)
That there is reluctance in physicians' attitudes toward the treatment of the obese patient is undeniable.(1,2) Most of this negative perspective is due to a long "institutional memory" by physicians of the debacle in the 1950s and 1960s from the use of amphetamines by infamous "pill mills" for weight loss. Doctors don't forget bad treatment ventures, especially when they bring wide publicity and negative medic coverage of the profession as a whole. Even more, they pass on their experiences to new generations of physicians as they go through training. The current continued negative climate and attitudes about the treatment of obesity has its roots in the distant past. It's unfortunate, but it is very real.
To show you just how real, a recent presentation at the North American Association for the Study of Obesity (NAASO) gives us some current insight in what I have known for years: most doctors don't want to treat obesity. And, more importantly, most don't want to learn how to treat obese patients. Here is the gist of the research:
According to a survey of some 218 physicians (a sample size of 22% of those sent the questionnaire) in the Baton Rouge area of Louisiana found a widespread disapproval of obese patients and limited use of current clinical strategies for managing obesity. A poster presentation by Catherine Champagne, Ph.D. was presented at the North American Association for the Study of Obesity meeting in Las Vegas, Nevada. Of the physicians who responded, 63% said most health professionals have negative attitudes toward obese patients and 64% said obese patients are resistant to long-term change. Seventy-four percent agreed with a statement characterizing obese patients as inactive overeaters who usually do not follow their doctors' advice. Nearly half of those responding (45%) said they would rather work with patients of normal weight.
Asked about the weight loss options that they gave their patients, the doctors sampled most often checked off calorie counting (31%), Weight Watchers (29%), and popular diet books (23%). Only 9 per cent of respondents recommended exchange lists, such as the ADA Diet Exchanges, for weight management; Even fewer (2%) suggested meal replacements (like Slim Fast™, etc).
Dr. Chanpagne, when questioned by Internal Medicine News, noted that most physicians were concerned about obesity in their patients and the nation. Half of respondents ranked obesity as a very serious health risk in their practices and 84% recognized obesity to be a disease similar to hypertension or diabetes. It is interesting to note that 56% of the physicians responding never prescribed any FDA-approved weight loss medications. This reluctance did not seem to depend on the patients' desire to take these medications. Interestingly, 39% of the doctors saying they "rarely" or "never" encouraged patients to follow the U.S.D.A. Food Guide Pyramid guidelines.
The findings of this study were reported in the Internal Medicine News, a leading independent newspaper for internal medicine specialists and published by the Internal Medicine News Group, a division of Elsevier Publications.
Obviously, there are some significant barriers to the appropriate use of prescription medications, diet recommendations, and exercise guidance among doctors as well as patients. As described in the presentation above, doctors are generally reluctant to get involved in the treatment of obesity. More importantly, most do not have the training to make recommendations on diet and exercise and guide the medical treatment options for these patients. So, they avoid them or, worse, just ignore the problem.
Patients who are considering treatment for achieving a healthier lifestyle and weight are also faced with significant hurdles. If you happen to mention you are thinking about getting medical help with obesity, you are likely to hear some horror stories from your "well-meaning" friends. "My sister's cousin took fen-phen and had some heart problems!" or "I heard that diet pills are addicting." You have probably heard these and other comments from your friends and co-workers. There are other the reasons these "helpful" people have tried to discourage you from going to "a diet doctor." Even your well-meaning (but poorly informed) personal doctor may have discouraged you from seeking specialized medical care for obesity. Some of their arguments, each addressed below, include:
1. Overweight people are usually perceived by themselves, by physicians in general and by society as a whole as simply lacking in self-control. Therefore, obese people hardly deserve professional help on a short term basis let alone on a long term basis.
As noted by Weintraub and Bray ("Medical Treatment of Obesity," Medical Clinics of North America, 73:237-249, 1989), "Obesity is stigmatized. Obese people are simply lazy; they lack willpower and are simply less motivated than others. In a survey on society's views of obesity, students at Michigan State University indicated they would prefer marrying a cocaine user, a shoplifter, or a communist over marrying an obese person."
It has been proven over and over in study after study that overweight people generally do not eat more than their "normal" weight counterparts. But the public and, unfortunately, the professional misconceptions are that being overweight is, by and large, a problem with simply overeating. It is clearly not. The "Human and Nutritional Evaluation Survey I" (NHANES I; Am J Clinical Nutrition 39:152, 1984) conducted by the U.S. Department of Health surveyed the eating habits of over 20,000 people across the US. The study categorically proved that the obese people surveyed actually ate less than people of :"normal" weight of the same age, sex, and other variables. Many similar surveys and observations have reached the same conclusion. Treatment of obesity is not a simple matter of "pushing away from the table."
In order to lose weight simply by "dieting." an obese individuals must reduce their food intake even more than normal weight people. It is probably due to the fact that some obese people are more efficient metabolically and have, over generations and generations, developed a highly efficient metabolism. This genetic tendency makes their bodies hold onto to stored fat more so than people without this genetic makeup. In order to reach and maintain a normal weight by "dieting,", these people are forced to live with chronic hunger. And that can only be held in check for a limited period of time. Eventually, as it does for all who try this, resistance to the overwhelming hunger breaks down and the eating resumes. And, when the dieter returns to the previous level of food intake, weight regain recurs. And, thus "yo-yo" begins and the cycle continues. And with it, comes frustration, guilt, and depression. .
Not only is treatment of obesity often unsuccessful from the patient's standpoint, but it is frequently frustrating for the average doctor. Changing a patient's lifelong pattern of behavior (what they eat, what they do for exercise, how they feel about themselves, etc.) is a long-term process for a doctor and a patient. It is also a process that is highlighted by relapses and "two steps forward, one step back" progress. To shield themselves from the sense of failure that inevitably comes with treating a overweight's person's lifestyle, most physicians refuse to take up the challenge. Instead, they tell the patient they need to lose weight, pass out a diet sheet and, maybe, a referral to a hospital dietician. When the patient is unsuccessful, the doctor feels relieved of his Hippocratic Oath and responsibility and avoids feeling inadequate. After all, it is the patient who failed, not the doctor! But, in the case of the obese patient, a physician's advice to "just push away from the table" and a diet sheet to cure obesity is about as helpful as telling a hypertensive patients to "just learn how to relax" and that will take care of the problem. Without support and additional resources, it simply doesn't happen.
2. Diet (appetite suppressant) medications are held to a higher standard in determining effectiveness than are medications for other chronic conditions.
Again, Dr's. Weintraub and Bray note, "The view that obese people need 'only to close their mouths' has caused us to demand a higher standard for evaluating medications used to treat obesity than we do for treatment of any other chronic medical condition. We accept the fact that serum cholesterol will rise when medications are stopped. We accept that ulcers will often recur following cessation of therapy. Even if the medications used in the above conditions do not "cure" the condition, we still consider it appropriate to treat the conditions with these medications, for life if necessary. Obesity is the only similar setting where failure of medications to "cure" an illness is not acceptable. Since none of the medications available for the treatment of obesity "cure" obesity, most physicians have been reluctant to use them at all.
3. Anorectics, or appetite suppressants, have a bad reputation in the general medical community because of the relationship of the medications to the street abuse of amphetamines and the inappropriate prescribing of this class of prescription drugs by a few "pill mill" doctors.
All currently available anorectics are, at least, chemically similar to amphetamines. But the commonly used anorectics (which includes phentermine, phendimetrazine, and diethylpropion) have much less potential for abuse than "speed" or amphetamines. Further, the proliferation of "pill mills" (dishonest doctors who prescribed amphetamines to anyone who requested and who could pay for them) have been cut back by the educational campaign of the FDA and the DEA. Unfortunately, many ill-informed physicians still feel that any physician who prescribes anorectic medications is practicing "bad medicine." They are, in a word, wrong.
4. The public and even physicians fear the "dangers" of the anorectics and their potential for patient abuse.
Short and long term medical studies have failed to document any significant problems with the addiction or abuse of anorectics. In our long experience, it is exceedingly rare for patients receiving anorectics in a strictly supervised program to demonstrate physiological or psychological dependence.
However, some patients may need the anorectics on a long term basis to achieve the needed reduction in food intake. In the medical literature, there are several studies that document the safety of these medicines for periods of 14-60 weeks. Side effects, which rarely occur at all, are mild and usually resolve with continued use of the medicine. The documented side effects include nervousness, insomnia, headaches, dizziness, nausea, dry mouth, and constipation. In our system, we start therapy with small doses and increase the dosage as tolerated by the patient. When side effects occur, they are easily managed by either reducing the dose for a short period or simply enduring them for a day or two until the body adapts to them. In my years of treating obesity, I have never had a patient who could not take some form of medication for improving their appetite control.
Michael Wintraub, M.D., of the University of Rochester School of Medicine and Dentistry, completed a study using anorectics for up to 5 years in the treatment of obesity with very favorable results and no significant problems. As a result of his work and others, at the ABC, we feel very comfortable in the use anorectics for life, if necessary and medically indicated, to control a patient's weight control.
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Albright Bariatric Clinic