Obesity

[mustangsally65]

I saw a post in the Topics in Healthcare forum and it made me think. The topic was about extra large ambulances for obese patients.

So how does obesity impact rural medicine? Big academic medical centers have extra-large beds and things like that, but how do small hospitals cope with patients who are too big for traditional equipment? How do you handle patients who need to lose so much weight?

Obesity is certainly becoming more prevalent, and it's obviously important for preventative medicine (like in primary care) to educate patients about getting their weight down and maintaining a healthy weight. But it's so easy to be accusatory and condescending if you're not careful, so how do you guys handle it?

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[McDoctor]

I think obesity is multifactorial and usually not the product of laziness alone. I think that (especially in the media) we do not do enough to tout the success stories of people who are able to manage the problem with changes in diet and lifestyle. I regularly see news stories about people who have taken the drastic step of gastric bypass surgery and I think that this leaves people with the impression that surgery is the only viable option for most.

I really try to force the lifestyle modification issue, and I refer all obese patients to a nutritionist since their insurance will cover it (including most medicaid programs). I find that most patient's don't take advantage of this but at least not due to lack of access. I try to point out the absurdity of fretting over somebody's LDL cholesterol when they weigh >35 BMI without being condescending, but I find it hard to justify prescribing a cholesterol lowering medication to a sedentary person. Again I stress that obesity is not their fault, but it is on them to do something about it. You definitely need to be artful and tactful when discussing weight with a patient. Its a challenge.

 

[deleted87716]

I try to point out the absurdity of fretting over somebody's LDL cholesterol when they weigh >35 BMI

Actually, it's even more important then. Obesity is a significant cardiovascular risk factor. Yes, losing weight will help lower their cardiovascular risk, but so will treating their lipids to goal, as well as controlling their blood pressure, blood glucose, getting them to stop smoking, etc. They're certainly not a therapeutic write-off simply because they're obese, although I've been known to use the "rearranging deck chairs on the Titanic" analogy to help motivate certain folks.

The real irony is the 2 pack/day smoker who's worried about catching bird flu...

 

[McDoctor]

Actually, it's even more important then. Obesity is a significant cardiovascular risk factor. Yes, losing weight will help lower their cardiovascular risk, but so will treating their lipids to goal, as well as controlling their blood pressure, blood glucose, getting them to stop smoking, etc. They're certainly not a therapeutic write-off simply because they're obese, although I've been known to use the "rearranging deck chairs on the Titanic" analogy to help motivate certain folks.

The real irony is the 2 pack/day smoker who's worried about catching bird flu...

You have a good point there.
What I try to get at is that the risk reduction afforded by Statin's for primary prevention is miniscule compared to what can be accomplished by significant lifestyle modifications. I cite a number of legitimite studies to back this up. But I don't refuse to prescribe Statins for patients if it is indicated, I just try to suggest that we are pi$$ing on a forest fire with pharmacotherapy alone.

 

[secretwave101]

I stress that obesity is not their fault, but it is on them to do something about it.

This sounds like circular wording that seems to skirt genuine meaning. I can see how it works in the clinic, though. You don't want to dishearten or demoralize anyone.

But I'm currently trying to lower my BMI from 27 to under 25. This translates into about 30 lbs overweight. And my obesity is TOTALLY my fault! I eat like crap and exercise like a corpse. There's no one to blame but me. Until I was willing to accept that, I wasn't ready to get my weight under control.

It's all my fault. Not McDonalds. Not urban sprawl. Not Cheetos. Not my mom or my grandma or great-grandpa Eddie. NOT MY THYROID! Nobody's forcing culinary sin down my throat every day, and I'm not stapled to the couch cushions.

I'm sure I'll have to tone that down a little for the clinic when I start residency in 2 months. But for me, taking responsibility was my first step. I'm down 10 pounds so far and still dropping. If I can develop the changes I've made into habits, I'll keep dropping and stay at a reasonable BMI.

 

[Danger Man]

Again I stress that obesity is not their fault, but it is on them to do something about it.

Wow, I am truly amazed!! You must be kidding!! This type of attitude allows people to take absolutely no ownership/responsibility for their own well-being. I think that you should empower (good liberal word) people by telling them that they are mostly responsible (genetics plays a role granted) for their own weight. Or did someone hold a gun to their head and force them to overeat?

 

[shemozart]

I really try to force the lifestyle modification issue, and I refer all obese patients to a nutritionist since their insurance will cover it (including most medicaid programs). I find that most patient's don't take advantage of this but at least not due to lack of access. I try to point out the absurdity of fretting over somebody's LDL cholesterol when they weigh >35 BMI without being condescending, but I find it hard to justify prescribing a cholesterol lowering medication to a sedentary person. Again I stress that obesity is not their fault, but it is on them to do something about it. You definitely need to be artful and tactful when discussing weight with a patient. Its a challenge.

At my residency clinic we deal with 5 HMOs and many other insurance plans, and then the medicare and medicaid stuff. Ironically, I was told many insurance plans will NOT cover nutritional counseling from a nutritionist for obesity alone - but will for some kind of related condition - i.e. GERD, DM2. Interesting. not sure about medicare.

As for the original part of the thread - most of the obese people I've seen are in the 200 (5 foot 2 women) to 350 (6 foot tall man) lb range - most rural hospitals can accomodate those sizes. The 425 lb woman I saw give birth in med school - not sure if a rural hospital could accomodate that (the big city hospital labor bed practically broke and 3 people were needed to turn her). And there are issues with ORs having equipment for the morbidly obese that will support their weight. But if a patient is THAT morbidly obese, (like 500 lbs), they should be at a major hospital - they are a huge operating risk I would think.

It makes me sick to my stomach to read stories like the one on msnbc.com or cnn.com (cannot remember which one) about how hospitals are installing all these special obesity related things (lit hallway floors b/c obese patients cast such a shadow on the floor it cannot be seen) - in 99% of cases, obesity is one's own fault!!!! People need to be able to admit to their own behavior!! But the article I read made Barnes-Jewish Hospital in St. Louis sound like they were advertising their obesity ancillary services to the general public. I like to think someday I'll be making a difference and motivating people so they don't have to end up at a place with special transfer cranes for getting from bed to the commode.

 

[McDoctor]

Most obese people struggled with their weight in childhood before they even had a sense of the health issues involved. They were obese before they had the ability to make lifestyle changes for themselves at a young age. In this respect, I think personal responsibility plays a smaller role in the cause and the problem is more complex than the general consensus on this thread so far is willing to concede. I strongly push personal responsibility to make the necessary changes, I just don't think obesity represents the defect of character that people are making it out to be.

Its far too easy for us if we dismiss the health problem as purely a consequence of poor decisions. We need to develop new strategies beyond the requisite lip service and gastric bypass surgery currently offered.

 

[sophiejane]

Its far too easy for us if we dismiss the health problem as purely a consequence of poor decisions. We need to develop new strategies beyond the requisite lip service and gastric bypass surgery currently offered.

This is an excellent point. The truth is, we know little about the etiology of obesity--why some people gain weight easily while others eat all they want with no consequences. That's why they call obesity a multifactorial illness.

Patients need to understand that you are their advocate and that you support them in what may be the most difficult thing they've ever done--losing weight. If they think you are judging them or even worse are "sick to your stomach" over their problem, you will both fail.

I admitted a patient last fall who weighed 540lbs. The resident and I gradually got him to talk more about his weight. He told us that he has never once in his whole life had the feeling of being satiated. He eats until he gets bored of eating because he doesn't have an internal mechanism that tells him he's full. If we hadn't really pushed him to get that information, we never would have known.

 

[mustangsally65]

He told us that he has never once in his whole life had the feeling of being satiated. He eats until he gets bored of eating because he doesn't have an internal mechanism that tells him he's full. If we hadn't really pushed him to get that information, we never would have known.

I went through a similar period of about a year where I ate every two or three hours and I still was hungry all the time. I would eat and eat, to the point of indigestion from putting so much food in my body, and I still didn't feel full. It was awful. I'd go out to eat with my parents and I'd eat more food than the two of them did combined. I found out later that I had excess blood insulin and it was making me hungry all the time, and I also had high blood sugar, so my body stored the energy away as fat and I was tired all the time since I wasn't getting any energy to my cells.

It's no wonder people get into a bad cycle of not exercising and eating all the time. You're too tired to exercise and you're too hungry not to eat. I think a judgement of inactivity and overeating due to simple lack of will power is too often made instead of a diagnosis of metabolic syndrome or pre-diabetes.

then again, it's easy to be judgemental. Sometimes it's much easier than everything else.

 

[Hard24Get]

The weight in childhood point that McDoctor made is a huge one. Sometimes it is just an obese family passing on their habits. But recently there has also been an influx of lazy parents using food as a reward, and that mentality will stick with them for the rest of their lives without hard, hard work. This, imo is tantamount to child abuse, and sets up horrible obstacles for the obese patient. This is a critical pediatric issue. Of interest, Dr. Lisa Hark at my school is hosting "Honey we're killing the kids" on TLC to address this issue...

 

[secretwave101]

This, imo is tantamount to child abuse

This is an extreme statement. The only way to make it more extreme is to say that creating obesity in a child is child abuse.

Frankly, that's exactly what should be said, I think. Nothing is more dangerous and costly in American culture than our hyper-caloric diets. Not guns. Not Osama. Not cancer. Not floods, hurricanes or earthquakes. I think our culture is too worried about political correctness, too worried about offending someone. So the problem grows (literally).

I'm about to start FP residency, and I'm a little frightened at how I will address this issue constantly with patients. I have strong, very harsh, feelings about obesity. I think I personally need the harshness and strength in my mind to keep my own weight under control. I have to HATE fat, and the extra calories that create it. Currently, my BMI has reached 24.8 - I've reached the airy climes of "non-overweight-ness", just barely. I've been throwing away entire half-gallons of ice cream, uneaten. I've asked my wife to hide candy and cookies. I've taken a small bite of a whole cake given to us for some celebration, and then dumped the rest. And I've learned a cynical joy in the phrase "save money, waste calories...currently you have it the other way around."

I don't know if I'll be a doc who inspires people...or pisses them off. I hope it's the former, but time will tell.

 

[sophiejane]

I just got the greatest new toy. It's software that allows you to enter foods and portions (they have like 8,000 different foods, including every restaurant chain you can imagine) and it analyzes your daily calorie, fat, etc. intake. You can put in exercise and for how long and it will subtract that (I love seeing my daily calorie allotment get bigger instead of smaller!). There's a spot for "checking in" where you can see your progress and it reminds you that you still have x amount of pounds to go to reach your goal.

I'm a total addict--it's just what I needed. I can imagine this would be a good tool for some patients as well, especially ones who aren't motivated to join groups or buy special foods.

My goal is to get from a BMI of 28 down to about 23 before I start seeing patients as a resident in about 14 months. I agree with you, Secretwave, there's nothing I find more hypocritical than a fat doctor telling his or her patients to lose weight! I also think I will have more to offer them and they will believe me when I tell them I lost 50 lbs, and tell them how I did it.

I think a lot of people fail because they go on these elaborate and expensive diets or join gyms with a dizzying array of classes and equipment and expect to make changes overnight.

You have to start low and go slow. The easier the program, the better the chance for success. I also think people need to make up their own diets, given a certain number of calories a day. It gives a lot more control and doesn't require learning a bunch of new recipes or denying yourself carbs.

 

[secretwave101]

SET ME UP!!! WHAT'S THE NAME OF THE SOFTWARE!

I've been doing this weight-loss stuff in my head all the time and I really never know what I'm doing. I try to stay under 2k calories/day and I figure I'm doing ok until I eat, like, a half a cookie. What's that? How'm I supposed to calculate a cookie? How many cal's in a dang cookie? 1000? 12? I have no freaking clue!

I've been losing weight with my pretty vague method of obsessing about calories and being careful to not blow out my glycemic index, but I'd be ALL OVER a program like that.

 

[sophiejane]

SET ME UP!!! WHAT'S THE NAME OF THE SOFTWARE!

I've been doing this weight-loss stuff in my head all the time and I really never know what I'm doing. I try to stay under 2k calories/day and I figure I'm doing ok until I eat, like, a half a cookie. What's that? How'm I supposed to calculate a cookie? How many cal's in a dang cookie? 1000? 12? I have no freaking clue!

I've been losing weight with my pretty vague method of obsessing about calories and being careful to not blow out my glycemic index, but I'd be ALL OVER a program like that.

I should really get commission for this, but here you go...

http://www.calorieking.com/software/ckdietdiarywin.php

7 day free trial, then you register if you want to keep using it ($45). Kind of steep but less expensive than Jenny Craig or even Weight Watchers. And there's a PDA version so you can calorie obsess 24-7.

It's perfect for obsessive compulsive people who love to see pie graphs and bar charts and numerical breakdowns...

 

[8744]

This is an extreme statement. The only way to make it more extreme is to say that creating obesity in a child is child abuse.

Frankly, that's exactly what should be said, I think. Nothing is more dangerous and costly in American culture than our hyper-caloric diets. Not guns. Not Osama. Not cancer. Not floods, hurricanes or earthquakes. I think our culture is too worried about political correctness, too worried about offending someone. So the problem grows (literally).

I'm about to start FP residency, and I'm a little frightened at how I will address this issue constantly with patients. I have strong, very harsh, feelings about obesity. I think I personally need the harshness and strength in my mind to keep my own weight under control. I have to HATE fat, and the extra calories that create it. Currently, my BMI has reached 24.8 - I've reached the airy climes of "non-overweight-ness", just barely. I've been throwing away entire half-gallons of ice cream, uneaten. I've asked my wife to hide candy and cookies. I've taken a small bite of a whole cake given to us for some celebration, and then dumped the rest. And I've learned a cynical joy in the phrase "save money, waste calories...currently you have it the other way around."

I don't know if I'll be a doc who inspires people...or pisses them off. I hope it's the former, but time will tell.

Whoa. You will piss them off. My program wants us to mention weight control to everybody who is even slightly overweight but I ask you, does your slightly overweight patient who is otherwise healthy (no tobacco, alcohol, and normal blood pressure) really need to hear at every visit that she is a disgusting fat body? I'd just tell them that they look fine, they're healthy, and while they could lose a few pounds (who couldn't) there's no pressing need.

No need to crush their self-esteem at every visit.

I'm kind of stocky myself but in excellent health from a cardiovascular point of view and will never get my BMI down from it's current 29.99999 to anything close to my "ideal" BMI. I'm 225 pounds. I'd have to get down to 185 or so to be at my ideal weight. There is no way in hell. Who wants to live like that.

You need to stop obsessing about food.

 

[sophiejane]

You need to stop obsessing about food.

You need to stop assuming you know what is best for everyone on the FM board since you really have so few productive and positive things to say to anyone here anymore.

I used the word obsess in a tongue-in-cheek way, as I am sure secretwave did. Those of us who are earnestly trying to improve our health don't need to hear those "life is too short not to be fat and happy" kinds of comments.

I want to lose weight because it will make me happier and healthier. Already, after only a few pounds, I have more energy and feel better about myself. Who are you to assume that just because you are overweight that everyone else should also be complacent and lazy?

I will never tell my overweight patients that they look "fine." There are ways (which have apparently escaped you) that a physician can encourage a patient to make some lifestyle changes without demoralizing them and calling them disgusting. If they are exercising and eating well and still just maintaining or losing weight very slowly, wonderful. I'm not saying we all have to be Barbie and Ken. But to sit here and argue over the benefits of exercise and good diet with another physician is ludicrous.

I thank the gods that you are getting out of family medicine. The world will be a better place.

 

[Hard24Get]

Anyway, can we forget about the grumpy bear's grumpy comments and go back to this fascinating discussion?

On how to talk to patients about weight, it seems that patient's are more likely to be dissatisfied with the issue not being raised rather than being raised disrespectfully PMID: 11031392.

The women's health department in student health, I believe, deals with obesity issues well. Though I am not overweight, they consistently on every check-up weigh me and there is a segment of the visit where they say, "Are you eating dairy and other calcium sources? How about veggies? Are you exercising? Let's see... you're weight's stable, so that's great - keep up the Pilates, though, and try to introduce more cardio because this will help to keep your heart healthy..." I don't get this at my other primary care visits, but we often do it in Pediatrics...

I believe the women's health approach lets the patient know that self-care and obesity are health issues important enough to bring up at each visit, and gives an easy way to introduce discussion if there is a problem, without having to say, "I couldn't help but notice that you're obese....

 

[deleted87716]

Though I am not overweight, they consistently on every check-up weigh me and there is a segment of the visit where they say, "Are you eating dairy and other calcium sources? How about veggies? Are you exercising? Let's see... you're weight's stable, so that's great - keep up the Pilates, though, and try to introduce more cardio because this will help to keep your heart healthy..." I don't get this at my other primary care visits

That's pretty much the way I do things, and I think it's the right way to go about it. I always try to keep the discussion focused on health. If the weight plays a role, it's discussed along with any other relevant health-related lifestyle issues. If the patient's doing something right (e.g., has started an exercise program, is losing weight, has cut down on their smoking, etc.), be sure to take notice, and give positive feedback. Chances are, they're expecting it.

 

[Hard24Get]

That's pretty much the way I do things, and I think it's the right way to go about it. I always try to keep the discussion focused on health. If the weight plays a role, it's discussed along with any other relevant health-related lifestyle issues. If the patient's doing something right (e.g., has started an exercise program, is losing weight, has cut down on their smoking, etc.), be sure to take notice, and give positive feedback. Chances are, they're expecting it.

That's great, Kent, and especially the smoking which I forgot to mention. I truly think that a caring primary care interaction like this can be the most important clinical care experience that a patient has. IMHO, it's really irresponsible to have continuity of care interactions, watching the patient become more and more obese, and/or continue to smoke, and only THEN have a serious discussion with them. By that time, their quality of life is already compromised, potentially forever. An ounce of prevention is worth a pound of pharmacological/specialist/subspecialist/surgical cure!

 

[8744]

You need to stop assuming you know what is best for everyone on the FM board since you really have so few productive and positive things to say to anyone here anymore.

I used the word obsess in a tongue-in-cheek way, as I am sure secretwave did. Those of us who are earnestly trying to improve our health don't need to hear those "life is too short not to be fat and happy" kinds of comments.

I want to lose weight because it will make me happier and healthier. Already, after only a few pounds, I have more energy and feel better about myself. Who are you to assume that just because you are overweight that everyone else should also be complacent and lazy?

I will never tell my overweight patients that they look "fine." There are ways (which have apparently escaped you) that a physician can encourage a patient to make some lifestyle changes without demoralizing them and calling them disgusting. If they are exercising and eating well and still just maintaining or losing weight very slowly, wonderful. I'm not saying we all have to be Barbie and Ken. But to sit here and argue over the benefits of exercise and good diet with another physician is ludicrous.

I thank the gods that you are getting out of family medicine. The world will be a better place.

You seem to be pretty touchy about this. Maybe you have a poor body image but there is no need to reinforce this on your patients. I repeat, if they're otherwise healthy leave it alone. You can't go on a personal crusade just because you have issues with food. It is...what's the word...judgemental.

 

[8744]

This is an extreme statement. The only way to make it more extreme is to say that creating obesity in a child is child abuse.

Frankly, that's exactly what should be said, I think. Nothing is more dangerous and costly in American culture than our hyper-caloric diets. Not guns. Not Osama. Not cancer. Not floods, hurricanes or earthquakes. I think our culture is too worried about political correctness, too worried about offending someone. So the problem grows (literally).

I'm about to start FP residency, and I'm a little frightened at how I will address this issue constantly with patients. I have strong, very harsh, feelings about obesity. I think I personally need the harshness and strength in my mind to keep my own weight under control. I have to HATE fat, and the extra calories that create it. Currently, my BMI has reached 24.8 - I've reached the airy climes of "non-overweight-ness", just barely. I've been throwing away entire half-gallons of ice cream, uneaten. I've asked my wife to hide candy and cookies. I've taken a small bite of a whole cake given to us for some celebration, and then dumped the rest. And I've learned a cynical joy in the phrase "save money, waste calories...currently you have it the other way around."

I don't know if I'll be a doc who inspires people...or pisses them off. I hope it's the former, but time will tell.

Man. You need help.

 

[Hard24Get]

You seem to be pretty touchy about this. Maybe you have a poor body image but there is no need to reinforce this on your patients. I repeat, if they're otherwise healthy leave it alone. You can't go on a personal crusade just because you have issues with food. It is...what's the word...judgemental.

Hi Grumpy Bear. I still contend that one can non-judgementally evaluate weight maintenance/loss as part of the preventative care section of the visit. There is no way it should come off as judgemental - did you think the dialogues that Kent and I proposed seemed that way? But these things DO need to be nipped in the bud BEFORE they become a health issue (that's why it's called prevention).

That being said, prevention's not a big part of EM, anyway, so I think you're safe now

 

[sophiejane]

You seem to be pretty touchy about this. Maybe you have a poor body image but there is no need to reinforce this on your patients. I repeat, if they're otherwise healthy leave it alone. You can't go on a personal crusade just because you have issues with food. It is...what's the word...judgemental.

Leaving PB's amateur armchair psychoanalysis out of this for the time being (actually I have always had a very good body image, but it's getting better every day, along with my general health as I continue to drop weight), he actually brings up an interesting point.

I know that I for one really didn't think about losing weight until I finally took a long hard look at myself (naked!) in the mirror. That, in addition to upward creeping LDL were all I needed to inspire me.

Our culture is bombarded with iconic images of too-thin models, which I think makes a lot of people overwhelmed when they think about losing weight, just as the elaborate diets and complicated gym equipment.

How do we convince our patients that they don't need to be a size 2, but that their BMI should be the focus?

I contend that you can't be healthy with an unhealthy BMI. You might be fine at the moment, but down the road, as metabolism slows even more, weight will continue to creep up and will be harder and harder to lose, along with back and knee problems at the very least, even in the unlikely event that they are able to maintain cardiovascular health at a higher than healthy BMI.

 

[deleted87716]

How do we convince our patients that they don't need to be a size 2, but that their BMI should be the focus?

Repitition, repetition, repetition, repetition...

I'm not talking about nagging, mind you. I'm simply suggesting that family physicians have an opportunity to help people adopt healthier lifestyle habits over the course of their lifetime, across multiple interactions. It's not something you're going to do overnight, and you're not going to get through to everyone. You also have to try to figure out what motivates that person. Not everyone cares how they look in the mirror, believe it or not. The idea of improving your cardiovascular health is pretty hard to wrap your brain around in a meaningful way, especially when you're young. Put it in terms that the person can relate to. "I'll bet if you started exercising, you wouldn't feel so tired all the time." Keep plugging; eventually, it just might sink in.

It's like that joke: "How many psychiatrists does it take to change a lightbulb? One, but the lightbulb has to really want to change."

 

[secretwave101]

Man. You need help.

I was just trying to voice honest thoughts and concerns among what I thought were intelligent and well-meaning colleagues. Vacuous and degrading statements like this help me see that this isn't entirely true.

I agree in principle with sophiejane's assertion that it may be a contradiction to say a person is "otherwise healthy" with an out-of-range BMI. Isn't that like saying the patient smokes, but is otherwise healthy? Or is "a little" diabetic?

Maybe our BMI calculations are incorrect, and there isn't enough variability to account for large-boned people, or extremely muscular people, etc. Maybe in the future we'll find that our BMI ranges are too stringent or not capable of accounting for myriad body types and compositions we have in our culture. So I don't want to over-do the BMI thing. But I'm taking it as gospel truth for my own personal body at this time.

 

[sophiejane]

How do you guys tackle childhood obesity in the clinic? Is there a different tack, or is it the same kind of repetition you use for adults?

 

[deleted87716]

How do you guys tackle childhood obesity in the clinic? Is there a different tack, or is it the same kind of repetition you use for adults?

It's harder. In many cases, the parents of an obese child are themselves obese. In order to successfully treat the child, you have to convince the entire family to change some pretty firmly-entrenched behaviors. If the parents aren't motivated, it's unlikely you'll have much success. Again, I try to keep the focus on health, not appearance. And yes, I'll keep bringing it up.

 

[RuralMedicine]

How do you guys tackle childhood obesity in the clinic? Is there a different tack, or is it the same kind of repetition you use for adults?

-Unless they're already above what could possibly be a healthy adult weight when you meet them (ie the 300 pound 4 year old I took care of as a resident) then I like to focus on weight maintenance through lifestyle changes so they can "grow into their weight".
-Exercise in this group is so key--exercise programs for kids seem atypical because when we were kids we probably logged a good 4-5 miles a day just running around playing. Encourage them to just get outside (easier to advocate in a rural area--when I was a resident parents wouldn't let their kids go outside because it wasn't safe in their neighborhood--and to be fair where they lived their fears were somewhat justified). I also recommend soccer (just no heading of the ball) because it has a decent aerobic background and even the overweight uncoordinated kids can excel with some work. Swimming is great but can be challenging if your community doesn't have an indoor pool (and that's a rarity in most rural areas).
-Just say no to soda, "juice" drinks, sugared cereal--tons of hidden calories here and they really don't miss it if you're firm that you're making changes.
-Approaching it in the context of the family is important since most 6 year olds aren't planning the menus. If you do FP or Med-Peds you may have an advantage of knowing the parents and their health history. Often these lifestyle changes will benefit the whole family and will be most successful if the whole family is motivated. I've also seen parents facing their child's obesity as the impetus to finally make changes.
-Unfortunately obesity is a huge pediatric problem and brings with it the related comorbidities and complications of HTN, OSA, DM etc. You need to screen for and address these issues with these kids as well.

 

[tridoc13]

-Unless they're already above what could possibly be a healthy adult weight when you meet them (ie the 300 pound 4 year old I took care of as a resident) ...

No way!!! Wow, could you please tell us a little bit more about this patient???

 

[McDoctor]

Personally, I don't think that the ten or fifteen minutes that I spend with a family can compete with the availability of soft drinks, high calorie school lunches, and general culture of inactivity that seems dominant with kids these days.

I make every service available to patients that is covered by insurance and provide info on what is available that is not covered (there is a program called ShapeDown). The problem is that I find patients unwilling to look into anything not covered by insurance.

I do sometimes think that a culture that puts at least some emphasis on appearance can help correct the problem. I just don't know where the line is wherein this encroaches too far into damaging one's self-esteem. I stand by my statement that the cause of obesity is usually not the fault of the patient, but the treatment is 100% lifestyle changes and this is best influenced by one's peers, not necessarily by one's doctor.

I would argue that our culture is in danger of becoming too accepting of obesity. Maybe just a touch of stigmatizing might motivate parents to spring for the relatively minor cost of educational programs on responsible weight management mentioned above.

 

[sophiejane]

I would argue that our culture is in danger of becoming too accepting of obesity. Maybe just a touch of stigmatizing might motivate parents to spring for the relatively minor cost of educational programs on responsible weight management mentioned above.

I think there's a lot of truth to this. Sometimes I wonder where people who weigh >300 lbs get their clothes, but apparently there are plenty of sources (I imagine Wal-Mart is one of them). There are XXXXXXXL versions of pretty much any fashion, unfortunately. Tube tops and spandex pants are just not attractive on everyone.

We get so little training in how to address this problem--it seems like we could use some skills borrowed from psychology here...

 

[deleted87716]

I would argue that our culture is in danger of becoming too accepting of obesity. Maybe just a touch of stigmatizing might motivate parents to spring for the relatively minor cost of educational programs on responsible weight management mentioned above.

I tend to agree. Something that drove it home for me a while back was seeing one of my nephew's elementary school class pictures (you know, the kind where the whole class lines up in rows on bleachers). In my old class photos, there was maybe one fat kid in the whole group (and as I recall, he was taunted mercilessly). In my nephew's class, fully two-thirds of the kids were overweight, and nobody seems to notice or care.

 

[RuralMedicine]

No way!!! Wow, could you please tell us a little bit more about this patient???

300+ pound 4 year old presented with respiratory distress, and impending hypercapneic respiratory failure after 2 day history of fever, non productive cough, and URI symptoms. Remote history of RAD vs. asthma [non-PICU admit in the first year of life with Nebs and steroids]. We intubated for impending respiratory failure with hypoxia and hypercapnia. Long ventilator course, ended up with a tracheostomy but did eventually wean from the ventilator[which was probably not so bad since he definitely had underlying respiratory insufficiency and chronic respiratory acidosis before this event]. Ultimately cultures were all negative, as was TSH, chromosome analysis, etc.

Basically Morbid Obesity-->Chronic Respiratory Insufficiency / Respiratory Acidosis superimposed Viral URI--> Respiratory Failure.

 

[shemozart]

I would argue that our culture is in danger of becoming too accepting of obesity. Maybe just a touch of stigmatizing might motivate parents to spring for the relatively minor cost of educational programs on responsible weight management mentioned above.

As others above have said, I also agree. I saw a patient with a BMI of 29.7 two days ago, and looking at her, she was the skinniest adult I saw that day (okay, residency clinic, only 6 patients that afternoon and two were OBs)....but if I cannot accurately judge weight anymore just by looking at someone, I feel like my perceptions have changed as well (due to the mass effect of so many overweight people in our society (no pun intended)). The stigmatization of being overweight/obese is slowly disappearing....

Weirdly, most of the kids (up to age 13 at least) that I've seen in clinic have been height-weight proportionate (if even skinny - sure, a couple overweight 10 years olds, but still...). Wonder if that's a selection bias as they usually are coming in for sports physicals. I've noticed the weight gain seems to be happening around puberty - so I notice the extra weight in patients around age 15 to 18. Seems like there should be some kind of intervention to target that age group, as well as the youngin's and their parents.....it's nice to see such a practical discussion of something that we all see everyday!

 

[sophiejane]

Is it just my experience, or are just about the only height/weight proportionate people >50 years smokers??

Pick your poison, I guess....fat + diabetes/heart disease or thin + lung cancer/osteoporosis...

 

[ecacofonix]

Hi,

It's been intriguing to me, so many of my obese friends have been trying every thing on earth to get lean and very few have succeeded. The funny thing is, most of them are doing the right things by the book! My mom for instance, is overweight, though not very overweight, and has been trying to lose weight in so many ways. She is active – does most of the housework herself, eats little-moderate, goes for daily walks – but no weight loss in the last two years!

I asked a couple of doctors about this, and one of the things that is emerging is that obesity cure plans have not worked for many people because many are recommended a “one-size-fits-all” plan, which I understand simply is not the case. I recently read a good article in which it was pointed out that customized treatments for individuals is perhaps the way forward. This means that you might have to approach physicians who are willing to consider individual traits in a comprehensive manner and suggest tailored diet & exercise plans. It also helps to remember that while in general the principle of moderate eating and good exercise does reduce weight, in some cases obesity could be owing to specific illnesses, or due to genetic reasons. In these cases, tailored recommendations from specialists are the best treatment. Hence my request to you would be to check out with a few obesity specialists to explore if they provide customized & tailored treatments for individuals. Just a thought.

Surgery is always an option, but I’d think one should consider it only after exhausting other options, simply because the other natural ways of losing weight also inculcate in your some very healthy practices which one might not bother to consider if one were to have a simple solution through surgery.

Check out if this useful page for those looking for more inputs on this area – http://www.billdoll.com/dir/health/q/obesity_cure.html . This is a page from the Billion Dollars Questions Site, and it not only categorizes obesity into the various types, but also provides useful to-dos and a number of web resources.

Some thoughts!

NS

 

[secretwave101]

Here's an interesting part. From NYTimes yesterday:

October 11, 2006
Seduced by Snacks? No, Not You
By KIM SEVERSON
Ithaca, N.Y.

PEOPLE almost always think they are too smart for Prof. Brian Wansink's quirky experiments in the psychology of overindulgence.

When it comes to the slippery issues of snacking and portion control, no one thinks he or she is the schmo who digs deep into the snack bowl without thinking, or orders dessert just because a restaurant plays a certain kind of music.

"To a person, people will swear they aren't influenced by the size of a package or how much variety there is on a buffet or the fancy name on a can of beans, but they are," Dr. Wansink said. "Every time."

He has the data to prove it. Dr. Wansink, who holds a doctorate in marketing from Stanford University and directs the Cornell University Food and Brand Lab, probably knows more about why we put things in our mouths than anybody else. His experiments examine the cues that make us eat the way we do. The size of an ice cream scoop, the way something is packaged and whom we sit next to all influence how much we eat. His research doesn't pave a clear path out of the obesity epidemic, but it does show the significant effect one's eating environment has on slow and steady weight gain.

Click here to read the entire article.

 

[erichaj]

I remember a really funny guy tell me the secret to not being overweight.

Here it is, Are you ready?

EAT LESS FOOD. LOL.

As americans we eat way way too much. We supersize everyting. If we go out to eat and they don't give us a huge serving we think we are being ripped off.

It is an institutional disease.

 

[racerx]

Tube tops and spandex pants are just not attractive on everyone.

Tube tops and spandex pants are not attractive on anybody. Especially if they are worn together.

 

[deleted6669]

I remember a really funny guy tell me the secret to not being overweight.

Here it is, Are you ready?

EAT LESS FOOD. LOL.

As americans we eat way way too much. We supersize everyting. If we go out to eat and they don't give us a huge serving we think we are being ripped off.

It is an institutional disease.

we finally agree on something
I just spent the summer"getting in shape", lost some wt, got my bmi down to 24, etc and ran my 1st marathon. lots of folks are saying "you look great, etc...what is your secret"? and I say "it's very complex...write this down...
eat less, eat better, exercise more.....

 

[deleted87716]

Yeah, it's easy to oversimplify things.

I recall Jay Leno doing a bit a while back, that went something like:

"What's so hard to figure out? Super-size fries...super-size ass!"

 

[erichaj]

we finally agree on something
I just spent the summer"getting in shape", lost some wt, got my bmi down to 24, etc and ran my 1st marathon. lots of folks are saying "you look great, etc...what is your secret"? and I say "it's very complex...write this down...
eat less, eat better, exercise more.....

I don't eat 1/3 of anything they put in front of me in a resturant.
I run or do some kind of exercise at leat 5 times a week for a minimum of 30 minutes.
I eat breakfast. A light one.
I give myself one day a week to eat what I want.

If you take in 500 less calories per day and burn 500 a day. Thats 1000 total less a day.

No secret, just simple math.

If you are overweight, then you just keep doing that until you get to ideal weight. Or as close to it as possible.

If you weight is 300 pounds then thats what it is, you just have longer to go.

PS. You told me you work in a hospital. I'd stay away from most of their food. It usually is filled with fat. Hospitals don't like to spend money on healthy things. Thats what I call Irony of it.

 

[flighterdoc]

It may not be their fault, they may be infected:

http://docnews.diabetesjournals.org/cgi/content/full/2/1/13

http://www.sciam.com/article.cfm?articleID=000EEADC-A456-13DA-A45683414B7F0000

 

[sophiejane]

I don't eat 1/3 of anything they put in front of me in a resturant.
I run or do some kind of exercise at leat 5 times a week for a minimum of 30 minutes.
I eat breakfast. A light one.
I give myself one day a week to eat what I want.

This is pretty much the exact advice an endocrinologist and diabetes expert I rotated with gave to his overweight patients.

They were forever bringing in these complicated diets to get his opinion on, the only thing he ever told them that really works is eating less and exercising more.

 

[erichaj]

This is pretty much the exact advice an endocrinologist and diabetes expert I rotated with gave to his overweight patients.

They were forever bringing in these complicated diets to get his opinion on, the only thing he ever told them that really works is eating less and exercising more.

Thats really are there is to it. People try to write all these books about diet and make millions doing it. The reality of it is that most people don't even stick to those diets.

People use to walk more and be less automated.

If every owerweight patient ate 1/3 less, walked about 20 to 30 minutes after one meal and did an overall resistance exercise at least once per week (it has been proven that even one weight lefting session per week will increase muscle mass significantly) they would regulate blood sugars and significantly reduce their chances of type II diabetes.

In the US we have the wrong impression of exercise. many people think they have to look like those guys that have their zip code at gym. those same people try to sell you all this supplements to lose weight and put on muscle. If you add up the cost of that stuff its more than a nice steak every night.

The best kind of protien is egg whites. It has every kind of aminoacid you need. so you can cook that and put it in a sandwich and there is breakfast that tastes good and give you most of your protein intake for the day.

 

[Disciple]

In the US we have the wrong impression of exercise. many people think they have to look like those guys that have their zip code at gym. those same people try to sell you all this supplements to lose weight and put on muscle. If you add up the cost of that stuff its more than a nice steak every night.

Agree,

What those ame guys don't tell people is that even with supplements, all it takes is oatmeal (or other forms of complex carbs), a little grape juice, and when bought in bulk, $3-4 of protein shakes daily.

 

[VolatileNavyDoc]

First, I want to say that I think this is an important topic. I don't have much to offer in the way of patient counseling, as I'm a GMO with the Marines, and most of my patients just want to know how to be able to bench press 300lb and run 3 miles in 18 minutes. However, we do see a few folks who are "out of standards". And like you guys have said, simpler is better. I've been researching diets lately, because I see so much out there, and it's kind of my responsibility to at least be able to speak intelligently about it. "Eat less, Eat better, Exercise more" is really at the core of them all, but we really need to have some more specific (yet simple) guidance for people.

One thing I tell my patients and family is to shop around the outside of the grocery store more than the center. This keeps you more in the fruit, veggie, milk, fresh meat section, and less in the ice cream, ho-ho, chips, and soda sections. Also, like someone said earlier, find some group exercise activity, and get involved with it. There are even some good workout schemes online now where people can post their results and progress. This way you can get to some of the people who are intimidated by gyms and aerobic classes. Almost everyone has the internet now, and the site I use is free.

 

[sophiejane]

I think the reason most people fail is because losing weight effectively is essentially about lifestyle change.

When was the last time you tried to overhaul your entire lifestyle? It's a daunting task.

I think if you start very, very small and build on small successes, you can have better results. I once heard a doc tell his patient (300lbs, sedentary)to start an exercise program with CRUNCHES. How about we start by walking around the block once a day? Parking farther from the grocery store doors?

These things have to not only be learned, but the bad stuff has to be unlearned--that is the kicker.

 

[erichaj]

I think the reason most people fail is because losing weight effectively is essentially about lifestyle change.

When was the last time you tried to overhaul your entire lifestyle? It's a daunting task.

I think if you start very, very small and build on small successes, you can have better results. I once heard a doc tell his patient (300lbs, sedentary)to start an exercise program with CRUNCHES. How about we start by walking around the block once a day? Parking farther from the grocery store doors?

These things have to not only be learned, but the bad stuff has to be unlearned--that is the kicker.

Or just go for a walk around the block.