Straight talk about weight loss

By BRIAN SODOMA

VIEW ON HEALTH

Robert Smith knew something was wrong a few years ago. At 430 pounds, the then 30 year-old mortgage officer and family man was mentally preparing himself for a long talk about weight loss with his doctor. But to his surprise, during a doctor’s visit, his blood pressure, cholesterol and other vitals came back normal.

“I couldn’t believe it,” he said.

But what Smith was probably more surprised about was the fact that his doctor still didn’t seem concerned about him losing weight. A few diet recommendations and a brief conversation about the food pyramid and the visit was done.

Even still, Smith joined Weight Watchers and began walking and lifting weights regularly. He has lost more than 150 pounds in the past three years and remains doggedly consistent with his exercise and eating routines.

“I’m maintaining now, enjoying myself a little, but during the time I was losing the weight, I was strict,” he adds.

But there are likely many more stories like Smith’s, as the topic of addressing obesity with patients and loved ones appears to still be a touchy one for health professionals. Dr. James Atkinson, a well-known valley bariatric surgeon who owns the Gastric Band Institute in Las Vegas, thinks it’s time the medical community should stop being so bashful about the obvious weight problems they see daily.

“There are multiple studies that have shown, in general, physicians don’t speak to patients about weight. It seems it’s just overlooked or just not talked about,” he says.

Nearly two years ago, Atkinson blurred medical business thinking by opening the Why Diet? Weight Management & Wellness Center, a medical weight loss clinic that is both a complement as well as an alternative to his surgical practice. Atkinson’s approach to surgery involves a psychological evaluation of patients at his wellness clinic and weight-loss begins prior to surgery. And there are plenty of patients who start losing weight, then opt to not even have surgery at all, he adds.

What Atkinson has also found is that there are still a strong number of doctor referrals for his surgery business. But those referrals lag for the natural weight-loss side of his practice. While 50 percent of his surgery patients come from doctor referrals, only about 20 percent of his other patients come as a result of a doctor referral.

Atkinson says often a primary care physician is “burdened with everything,” when it comes to a patient’s overall health. Doctors often talk about the symptoms — such as diabetes, high blood pressure or high cholesterol — associated with being overweight or obese but don’t come right out and say that it may be time to lose weight, he adds.

“(Bariatric specialists are) not specialists in diabetes and high blood pressure. We’re really just going to deal with their weight,” he says. “For the doctor who has a patient with a weight problem in front of him, there needs to be a way for him to know it’s time to refer.”

Even with the body mass index (BMI) as an aid to gauge a person’s body fat, too often doctors still avoid the conversation. Atkinson says that by the time he sees a bariatric surgery referral a lot of problems could have been avoided with a more proactive approach. Surgery is only recommended for patients with a BMI topping 40, or for people who are usually 100 pounds or more overweight, he adds.

TRENDS

There’s no shortage of statistics regarding America’s growing obesity epidemic. According to the Centers for Disease Control, in 2009, 33 states in America had an obesity (BMI higher than 30) rate equal to or more than 25 percent. Mississippi topped the list with a 34.4 percent rating, or more than a third of its residents categorized as obese.

Through the years, studies have attempted to look at the issue of doctor referrals for obesity and weight control. Often these studies point to primary care, family practice or pediatric health professionals not knowing clearly when and how to address the weight issue. In many cases, obesity or a weight problem is identified but an incomplete approach to the issue follows.

In a 2004 issue of Pediatrics magazine, a published study conducted by University of Pittsburgh School of Medicine reviewed 2,515 patient visits spanning roughly 14 months of activity. Through the records, 244 patients met the study definition of obesity, which was a weight of greater than 120 percent of the 50th percentile of weight for height in children under 5 years old and BMI of greater than the 95th percentile for age and gender for those over 5 years old.

In the study, 81 percent of the obese patients’ charts included an adequate diet history, but only 27 percent had any description of the child’s activity level. Dietary changes were recommended for 71 percent, but increased activity was only recommended in 33 percent of the cases and limiting television in only 5 percent. Further, identifying obesity as a problem only occurred in half the cases.

“Although the prevalence of childhood obesity has now reached epidemic proportions, it was under-recognized and under-treated by pediatric primary care providers in our study,” the study abstract noted. “This study highlights the need for increased awareness and identification of obesity in the primary care setting, especially among younger children and those with mild obesity.”

And while doctors may seem reluctant to refer patients for weight-loss care, there are still positive results seen when they do. A United Kingdom study published earlier this month on BMC (BioMed Central) Public Health looked at the country’s National Health Service’s Weight Watchers referral system between April 2007 and October 2009 and found among the more than 29,000 referrals there was a median weight change of 3.1 percent in 12 weeks. Thirty-three percent saw losses greater than or equal to 5 percent of initial weight.

USE THE BAD NEWS

Getting patients out of the doctor’s office with illnesses and into weight-loss programs before surgery requires great bedside manner, says valley family practice physician, Dr. Daliah Wachs.

“It’s a lot so sit down with a post-menopausal woman who comes in and says ‘my doctor said I was fat!’ and then talk to them about this,” she says. “You can lose a patient.”

For Wachs, addressing medical issues is often the bridge to the weight loss conversation, she says. She highlights a few conditions often associated with excess weight that are great for doctors to use to kick start the conversation. Sleep apnea in particular is one that doctors can tie to excess weight quite easily.

“It’s easy to say ‘one way we can help this is by decreasing the weight,'” she says. “I also think doctors should sit down with patients and go through their blood work and go through the timelines. … That way we can say ‘see when you weighed forty pounds less, your cholesterol was here (lower).'”

Rachel Handley is a psychotherapist who works with bariatric patients in Atkinson’s clinic. She says it’s important to ask patients a lot of questions, making sure not to compare them to anyone else along the way. Questions about how weight is affecting them physically and emotionally are how she angles her conversations.

“Most of the people that come to us are looking for a solution,” she adds. “When you’re asking questions, it shows you’re interested in them and not just trying to sell a surgery.”

NIH TIPS

The National Institutes of Health also offers tips to health professionals on how to address weight management with patients. The tips range from gathering information on opinions and attitudes as well as more specific goal oriented suggestions for more motivated patients.

Some of the tips include: focusing on how a small weight loss of 10 percent can reduce considerable health risks; selecting “measurable and achievable goals;” discussing reasons and motivations for losing weight; delving into previous attempts at losing weight; learning a patient’s attitude towards exercise and asking about levels of support they may have at home and with family. Potential barriers to success should also be evaluated.

Time constraints are also a concern among primary care physicians, adds Wachs. Low insurance reimbursements put doctors in a situation to take on high patient loads, decreasing the amount of time with a patient. And in the case of a lifestyle change, time is probably the most needed element to help correct the problems.

“With weight-related issues, it takes time and patience to talk to people about those things and doctors don’t really have a lot of it,” she adds.

INSURANCE BARRIERS

One suspected barrier to referrals to weight-loss programs is a lack of insurance coverage. Today, it’s very uncommon to find insurance carriers who will cover one, but some do. And with bariatric surgery becoming more accepted option in morbidly obese cases and a commonly covered procedure, insurance carriers are warming to the idea of preventative maintenance as well. Atkinson believes we may be close to seeing weight-loss program coverage becoming the norm.

“Insurance companies are interested in more preventative medicine. I expect you’ll see an increase in coverage in the next couple years,” he says.

BEYOND THE REFERRAL

When a patient, whether at the encouragement of a medical professional or because of ones own self-discipline, finally decides on a weight-loss approach, the real mental work begins, asserts Handley.

The mental health practitioner says optimum health is about “mind over eating.” Whether she is counseling a pre-surgery patient or not, the mind is often a patient’s biggest obstacle.

“Many patients think surgery is the answer and think they’ll have the surgery done and never gain the weight back. … But unfortunately the surgery is just for their stomach. It’s not for their brain,” she adds.

Those who have yo-yo dieted for years or who have been in denial of their weight problems have “unconsciously become addicted to food,” Handley says.

Changing your thinking about food isn’t a short process. But asking yourself why you’re eating and if you’re even hungry while using a food journal are keys to success, she adds.

“If we thought of our bodies as a Ferrari what kinds of fuel would we want to put into it?” she asks.

Wachs says weight loss programs that a person can use long-term are the most beneficial. She says programs like Nutrisystems are difficult because users need to buy specific foods from the program facilitators. Programs like Weight Watchers, which offers essentially a calorie-counting technique masked by a points system, are more helpful because the system applies to every day foods.

“Weight Watchers appears to be a little more effective. You can walk into a restaurant and do it,” she adds.

But she also says that a little bit of weight loss is the best motivator for patients. Just starting out and seeing even the slightest bit of success can create a healthier addiction to becoming fit.

“It’s a snowball effect. It gives reinforcement on the psychological side,” the doctor says.