obesity tx

[dr.smurf]

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ok so we all know how the u.s. is a fat nation! all we have been hearing lately is that obesity has become an epidemic and is liked from everything from cancer to the htn and dm. but, how do we as physicians tackle the obese pt??

aside from diets which these pts have been on time and time again and just fall off the wagon..or rather onto the wagon...buffet wagon that is...what do you all thing about using sibutramine (meridia) or even the central adrenergic stimulants (i.e. phentermine) to assist these pts in loosing the weight? anyone have any luck using these. it seems most of my attendings are reluctant in using them or it just isnt common practice for them. dont get me wrong...im not being insensitive. but, its not only hard for the pt but the physician treating as well.

any thoughts??

 

[Seaglass]

When I rotated in family practice I was at a very busy and well respected family practice residency where they had a nutritionist on site etc. etc. I actually asked them specifically about Meridia and they said that they had only seen very modest weight loss and felt that it was mostly due to just calorie restriction. According to them their patients didn't feel like it helped them say no to food too much. Obesity is a dangerous illness because you don't feel like you're sick until you're too far gone.

C

 

[Doreen]

Growing up as a fat child to the morbidly obese adolescent, I actually give thanks to Phen-Fen which helped me shed 90 lbs about 7-8 years ago and I only gained back 15lbs 2 years later and have since maintained my weight. I never really exercised as a child. My days consisted of going to school, doing my homework, and then either reading a book or watching tv. Phentermine not only suppressed my appetite but gave me alot more energy and so I began walking 3-4 miles a day without gasping for air .
I think prescription diet pills work best for those who want to make a serious effort to lose weight. If you're obese because you like to constantly supersize your fast food meals then you need to make the effort to change your diet first because as soon as you stop taking the pills you'll gain back if not more. I hardly eat fast food but since I'm from the caribbean rice and beans with plantains really put on the pounds if you don't watch yourself

 

[scootad.]

gastric banding

 

[alphaagonist]

If you want to lose weight consider a laproscopic gastric bypass if you BMI> 40% and less than 60%..... 😎

 

[lattimer13]

caffeine, cocaine, amphetamines, lots of dietary fiber...

 

[Purifyer]

Although I'm admittedly ignorant on the subject, why not just prescribe Metformin?

 

[fourthyear]

Okay, this will sound insensetive, but...
Fat people have had a long time of bad lifestyle choices to get fat. It's laziness, our convenient lifestyles (cars, elevators), sedentary hobbies, and lots of large-portion unhealthy food options more available to busy people than healthy food choices. America needs a huge attitude overhaul, not some magic pill or magic surgery to fix this. Even with the meds or the surgery, major lifestyle changes must be made. In fact, after gastric bypass, people who return to trying to eat junk food or large quantities of food get sick, throw up, return to the hospital over and over, and generally lead a pretty miserable life. The ones who lose weight and end up happy have to stick to a very strict low sugar low portion diet every single meal for the rest of their lives - no more holiday splurge, no more sharing candy at the office, ever again. It's really not a quick fix.
Dr. smurf, I don't know how to change patients' behaviors and lifestyles. I really think they have the responsibility to self-motivate and do it. Not a sympathetic doctor answer, but it's the truth.

 

[mfleur]

I've invented a new diet...Its call "Get off your ass and go to the gym"

 

[fourthyear]

I've invented a new diet...Its call "Get off your ass and go to the gym"

Exactly! it's pretty simple.

 

[Febrifuge]

Of course it's a matter of personal responsibility, but are you seriously suggesting that laziness and lack of character is the sole, or even the main reason for the sudden (last ~20 yrs) explosion of obesity?

This is the first time in known history that the poor have been fatter, and the rich have been thinner.

Or, put it another way: you have 45 minutes for lunch. You have $4.00. Go.

Are you going to eat something healthy, or are you going to eat what is available to you everywhere you turn? If you find something healthy today, what are you going to have on your lunch break tomorrow? There are only so many Wendy's salads a person can have.

Yes, with the application of self-discipline and awareness, you can navigate the maze of toxic crap that America's corporate food conglomerates so graciously throw in the trough, and find your way to something reasonably healthy. But for the first time in a very long while, healthy food is the exception and not the norm.

It is way more complicated than "fat people are lazy and don't care about their health."

 

[fourthyear]

Okay, I go to the cafeteria for lunch maybe 4 days a week (I unhealthfully skip about a day a week b/c I'm too busy occasionally to grab any real lunch at all). While I'm buying one hearty bowl of soup OR one deli sandwich WITHOUT chips and water to drink, there are fat people next to me choosing soup, salad, AND the fattening entre du jour with a soda too of course. I go to the cafeteria for breakfast maybe one or two days a week and get one egg and a piece of toast, while some fat person next to me gets two eggs, bacon, donut and juice.
Hmmm...same cafeteria, whole lotta calorie difference.
Personal choice and responsibility.
At one of the hospitals I rotated at breifly this year, there really are very limited food choices, so guess what - I brought my lunch! What an idea! No fridge available to me, used the old fasioned cooler and packed it every morning at 5 am - why can't people who go to work at 8-9am find time to do this? You make it sound like they are forced to buy the quarter pounder value meal! Give me a break!

I work 80 hours a week, spend average of 2 nights a week on in-house call, yet still manage to get about 20 minutes exercise 3 days a week most weeks. If I could even dream of having a 40 hour week like most people do, I would love to work out more. But they go home and sit by the tv for 4 hours saying they are too tired from work to get outside and be a little active.

I'm sorry, I just can't blame the fast food industry on people making poor choices with their lives and their health when I manage to live a busy lifestyle on a budget and stay within a healthy BMI range. Yes, I think the problem is laziness and lack of responsibility, plain and simple.

 

[ma-bas]

All I have to say, without singleing out anyone in particular, you cannot expect all of your patients to have the same value system, motivation, self-esteem, education or income as you. You will get no where, and instead of being helpful you will always wonder why you can't get your patients to lose weight, or take their medication, or go to PT, or check their blood suger or do whatever it is you deem necessary as their provider to make them better. You will be frustrated that your patients are non-compliant, and certainly that can be frustrating. If you always have the if I can do it they can too attitude, you won't be able to see why your pateints are non-comliant and you won't be able to change your intervention. And then if your patients continue to be non-compliant the fault is as much yours as theirs. They may be motivated but have other barriers to success.


How do you get a 250 40 y.o woman to the gym when she hasn't exercised since junior high? How do you get someone who has stretched out their stomach to reduce their portions to half without feeling hungry, empty, deprived and depressed? How do you get a lower income patient to eat healthier food? It isn't impossible, I do it every day, but it take creativity, time (which most physicians don't have) and being non-judgemental.

 

[Whisker Barrel Cortex]

how do we as physicians tackle the obese pt??

Very carefully. If you tackle them the wrong way, they may fall on you.

 

[zinjanthropus]

My dissertation is on the environment of obesity, public policy and food choice so I feel inclined to say something in this thread. Until overweight and obesity is taken seriously by clinical physicians and legislators, we are not going to decrease the incidence of excess weight.

Personal responsibility is critical but we must remember that our responsibilities are prioritized and exist within a larger context. Is it the responsibility of consumers to understand that trans fats have a higher risk ratio for CDV than other saturated fats? Is it the responsibility of consumers to understand that high fructose corn syrup can be placed in products without listing the amount in the product and with the product still bearing the label "reduced sugar" or even "sugar-free"? How about that "net carbs" might actually impact blood sugar and decrease insulin sensitivity and clearance?

Furthermore, it is our responsibility to make good choices but those choices are limited by the available foods and by our socioeconomic situation. Each day people balance two budgets - caloric and economic. You might not realize that you are making food choices based on some necessary caloric budget, but, proximally, you indeed are. Therefore, given X amount of dollars and the need for Y amount of calories, you have to make choices. My research has shown that price per dollar, cheap foods are high in calories and more likely to leave you susceptible to obesity. Do we see increased obesity prevalence in low socioeconomic groups because of this, combined with little time to make food choices, less nutrition education, and less available options?

Maybe our individual histories have something to do with an obesity. How about alterations in physiology due to growing up under undernutrition conditions, thus shifting the respiratory quotient away from fat oxidation?

I work hard to make good nutrition choices, but yet I still feel duped and limited at times at the grocery store and at restaurants due to under-reporting of all the nutrition data. If I was an everyday consumer, and not a person with a vested interest in nutrition, then my dietary choices would even be more difficult. To make matters worse, we are not taught to be strict and meticuluous consumers when making food choices - marketing has worked well to create a culture akin to this.

Public health and preventive medicine have done an excellent job at documenting the obesity epidemic. Now it is time to erase the stigma that exists around this epidemic clinically. If there are meds that show efficacy in decreasing weight, these meds must certainly be considered as options and tools in the obesity epidemic.

 

[cubby]

Check out the website for the American Society of Bariatric Physicians.

http://www.asbp.org/

When I first heard of bariatrics as an MSII, I thought it had something to do with bariatric pressure--like deep sea diving medicine or something. The ASBP's purpose, as they define it, is to "advance and support the physician?s role in treating overweight patients." I ended up working with an FP last year during my family practice rotation who was also a certified baritrician--he was able to obtain fantastic results for many of his patients. By carefully using certain medications, supplying motivation and encouragement, and manipulation of the body's physiology, I think physicians can make a huge difference in the war against obesity. The war needs to be fought on many levels--societal, community, and individual, among others--so whatever your "bag" is, it would be great to see more docs and prospective docs become better educated and equiped to treat obesity.

On this ASBP website, you'll find practice guidelines, FAQ, opportunities to get involved with bariatrics. Definitely worth checking out.

 

[tofurious]

overweight and obesity is taken seriously by clinical physicians and legislators, we are not going to decrease the incidence of excess weight.

The reality of medicine is that too little money is/will be spent on prevention. Until overweight/obesity is seen as a killer (despite the fact that it usually kills through cardiovascular diseases, although I treated a lady who was dying from her obesity due to obesity-induced COPD) as smoking was, physicians are not going to be reimbursed for treating obesity. For a long time, cigarette makers said that smoking was not a killer while the smokers stayed silent. Now it is the overweight/obese individuals who are saying "we are big but fit" as they try to catch their breath. Every obesity conference you go to, you hear the message "learn from our experiences with smoking". It is the legislators who need to do something, as people lack the free will to make right choices.

the label "reduced sugar" or even "sugar-free"? How about that "net carbs" might actually impact blood sugar and decrease insulin sensitivity and clearance?

We have already dumbed down the message "fat is bad". This backfired when people started forming BBW and other fat-and-proud groups. If people are unable to understand complex messages and refuse to accept simplified versions of such, they must be held accountable for the consequences.

choices are limited by the available foods and by our socioeconomic situation.

That I agree with. The poor are left out of all the current diet strategies. They can't afford to eat all the fruits and vegetables that are sold on a per ounce basis. They can't afford the gym membership, and they can't afford to not work a second job so they can stay home and watch their kids. This is a big social problem that needs to be addressed through reforms in the welfare system, WIC, food banks, and other social agencies, AGAIN requiring legistlative foresight and initiative. But people who belong to the middle and upper classes of our society are not immune from weight issues.

Now it is time to erase the stigma that exists around this epidemic clinically. If there are meds that show efficacy in decreasing weight, these meds must certainly be considered as options and tools in the obesity epidemic.

There are medications that help people quit smoking, but the most effective strategy was banning smoking from public places. Bariatric surgeries are very effective in short term weight reduction, but the 5-year failure rate is very high as patients just go back to their old way of eating (poorly yet heavily). It is a sad admission among clinicians that you can teach the patients to make all the right choices in the world, but you as a clinician will not be able to make the choices for them. Only legislators can.