Question for Medical Students

[Sparda29]

I just wanted to know what is being taught about obesity in medical school at this time.

Is it being taught that it is a disease, symptom, or cause?

When I was shadowing a physician who specialized in respiratory/sleep medicine, he basically thought that all of his sleep apnea patients were lazy fatasses.

All he told them to do was to use this machine to help open up the airways and to lose weight, nothing at all on how to lose weight, he did not prescribe any drugs for weight loss, he didn't recommend any surgeries for weight loss, and he did not give any consultations to a bariatric specialist, or nutritionist, he just told them to diet and exercise. Why is this "diet and exercise" ideology still being spread around when everyone knows that it does not work.

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[janneyc]

Technically, diet and exercise does work. It's more patient compliance that doesn't seem to work. How do you correct that problem though?

Here, it appears that obesity is being taught as a condition with a separate focus on treatment. Education about healthy lifestyles, etc. I assume it's more how the doctor's personal stance is on the subject. It seems to me you could be taught it's a symptom, a disease, etc., but your own personal viewpoints on obesity might affect how you prescribe medications or recommend treatments.

 

[howelljolly]

Because no surgery, meds, or continuous positive airway pressure devices will make any difference if the patient does not start with, and stick to a strict diet and exercise plan.

Medical management is the last thing you want to do.

And, everyone knows that the process is multifactorial, and those factors are slightly different for each patient. Diet and exercise is the only thing that does "work", and provides the least amount of complications.

 

[87138]

Technically, diet and exercise does work. It's more patient compliance that doesn't seem to work. How do you correct that problem though?

What he/she said. Diet and exercise most certainly do work; however, changing someone's behavior/attitude/SES is generally pretty difficult, and these are all pretty big factors.

 

[howelljolly]

Its funny that you mention this because we just had the lectures on obesity today in the class. As far as how it is "taught" per say, the lecturer did not show his bias about it. It was a bit ambiguous, but most of the points made supported by studies inclined to the conclusion that obesity, in general, is a problem resulting largely from personal decisions and behavioral pattern more so than genic determinance. The genes play a role, but the genes have been there for ages. In other words, genes didn't change, but our lifestyle did. This seemed to be the content of the message in our lecture. He never went as far as saying that fat people are just lazy though.

Hope this helps.

Interesting

 

[meister]

Of the things you mentioned, I think a nutritionist would be a good referral for a respiratory/sleep medicine guy, not surgery or weight-loss medications. Those should be the last possible option. Diet and exercise, with greater emphasis on diet, should be the default for everyone.

I mean who is going to deny that the number one cause of the obesity epidemic in the US is our atrocious diet? If we all started eating salads and grilled chicken all day and oatmeal for breakfast the nation's BMI would relax down to 25 in a couple decades.

 

[WellWornLad]

It's presented in the context of an epidemic at our school. In 1985, the highest obesity rates by state were around 10-14%. In 2007, only one state (Colorado) is below 20%, and the highest rates are pushing 40%. There's no genetic/familial explanation for that growth (pun intended).

Why is this "diet and exercise" ideology still being spread around when everyone knows that it does not work.

It's hard to wrap my head around the ignorance of this statement. Diet and exercise are miles ahead of any other treatment in terms of efficacy and safety. There are barriers to diet and exercise, including access, affordability, education, and compliance, but to say that diet and exercise don't work is patently ridiculous.

Gastric bypass operations, for example, are very successful in reducing obesity. They work by simply enforcing diet compliance - if you eat too much, you get sick. It's very risky and unpleasant, however, so diet alone (or diet and exercise) is vastly preferable.

Basically, if diet and exercise didn't work "The Biggest Loser" would be a very anticlimactic show.

 

[87138]

If we all started eating salads and grilled chicken all day and oatmeal for breakfast the nation's BMI would relax down to 25 in a couple decades.

You don't even need to go that far. For actual weight loss, you can get skinny as hell on Ho-Hos and Twinkies, just like you can get fat from grilled chicken and brown rice. It's all about quantity. Calories in vs. calories out.

That said, of course things like nutrient partitioning and such can have an effect, and if you're constantly spiking insulin levels with sugary foods it's going to be tougher than if you're consuming the same number of calories but with "healthy" foods. However, it does essentially all boil down to number of calories. This is talking about weight, not about overall health (the two of course should never be confused).

And to further confound things, most people have no idea what "healthy food" actually is.

 

[Sparda29]

It's presented in the context of an epidemic at our school. In 1985, the highest obesity rates by state were around 10-14%. In 2007, only one state (Colorado) is below 20%, and the highest rates are pushing 40%. There's no genetic/familial explanation for that growth (pun intended).



It's hard to wrap my head around the ignorance of this statement. Diet and exercise are miles ahead of any other treatment in terms of efficacy and safety. There are barriers to diet and exercise, including access, affordability, education, and compliance, but to say that diet and exercise don't work is patently ridiculous.

Gastric bypass operations, for example, are very successful in reducing obesity. They work by simply enforcing diet compliance - if you eat too much, you get sick. It's very risky and unpleasant, however, so diet alone (or diet and exercise) is vastly preferable.

Basically, if diet and exercise didn't work "The Biggest Loser" would be a very anticlimactic show.

See the thing with "The Biggest Loser" is that the participants are pretty restricted on what they eat and are pushed to the limit by the trainers during exercise. When I go to the gym, I don't even do 50% of what they do on that show. Their diet is also tightly controlled and access to bad food is pretty much cut off. No wonder they lose weight, they have like a 3000 caloric deficit every day.

So yeah, what I meant by diet and exercise is that it works in theory and when the subject is controlled, but just telling someone to diet and exercise without fixing their dietary and exercise habits isn't going to accomplish anything.

 

[Sparda29]

You don't even need to go that far. For actual weight loss, you can get skinny as hell on Ho-Hos and Twinkies, just like you can get fat from grilled chicken and brown rice. It's all about quantity. Calories in vs. calories out.

That said, of course things like nutrient partitioning and such can have an effect, and if you're constantly spiking insulin levels with sugary foods it's going to be tougher than if you're consuming the same number of calories but with "healthy" foods. However, it does essentially all boil down to number of calories. This is talking about weight, not about overall health (the two of course should never be confused).

And to further confound things, most people have no idea what "healthy food" actually is.

Yeah, the only time I was able to get my weight down is when I went on the Atkins diet but once I left the diet, my weight went up by twice of how much I lost.

However, my blood work, cholesterol, triglycerides, blood glucose is perfect.

 

[GreenShirt]

It's hard to wrap my head around the ignorance of this statement. Diet and exercise are miles ahead of any other treatment in terms of efficacy and safety. There are barriers to diet and exercise, including access, affordability, education, and compliance, but to say that diet and exercise don't work is patently ridiculous.

Gastric bypass operations, for example, are very successful in reducing obesity. They work by simply enforcing diet compliance - if you eat too much, you get sick. It's very risky and unpleasant, however, so diet alone (or diet and exercise) is vastly preferable.

Basically, if diet and exercise didn't work "The Biggest Loser" would be a very anticlimactic show.

These are huge barriers for many people and cannot be underestimated. I just moved to rural America where there are no parks or side walks to run in, no gyms within 30 min driving and no dining out options beside fast food. You can't just tell patients here to sign up at the gym or pick the healthy options on the menu when they dine out as you could in the city.

I think the physician you worked with is well aware of the issues with compliance. He can tell people to diet, exercise, stop smoking until he is blue in the face but it doesn't mean that the patient will do anything about it. Gastric bypass surgery is effective but risky. It also requires major compliance with a strict diet and exercise plan. Patients will drop weight like nobodies business for the first year or so. After that they plateau. If they don't maintain a proper diet when they plateau, then they can gain back the weight.

Obesity is a huge problem in the US and doctor's will have to learn how to effectively treat patient's with this problem.

 

[howelljolly]

Gastric bypass surgery is effective but risky. It also requires major compliance with a strict diet and exercise plan. Patients will drop weight like nobodies business for the first year or so. After that they plateau. If they don't maintain a proper diet when they plateau, then they can gain back the weight.

thats an understatement.

Shows like The Biggest Looser do not show you the whole story.

If you maintain the same level of activity, but cut out 500 cals per day, you'll lose one pound per week. Thats not a lot, but its safe and steady. But Im pretty sure, unless you make an effort, its difficult to maintain the same baseline of activity... let alone increase it, when you have a 500cal deficit.

If you lose weight on the Atkins diet, this tells you something about your baseline diet, as well as about your own metabolism.... Think about what's going on in your diet.
If I were to go on the Atikins diet, I wouldnt loose a pound.

One thing that Im sure that many people do is be dishonest with thmselves, about how much they actually work out, and how much they actually eat. That single cheeseburger WILL ruin your weeks worth of dieting and exercise.

 

[mjl1717]

It taught like its a high impact disease that can lead to MANY others ( I wont even start the list)!

1) Here in the U.S. 2/3s are overweight and 1 out of 3 kids are obese..

2)As said its very hard to change ones life style..

3) But as HJ said and contrary to what many think losing one pound a week IS DOABLE..

4) I dont see anyone overweight in Afghanistan..

5)Remember this is the tempation, festive and party time of the year starting with Halloween and ending the beginning of January..One is more likely to eat junk food , ice cream and cake etc..So this would be the worse time for someone to diet..

6)Many are in denial!!!..Sometimes people lose weight but it comes right back..

7)One strategy. Tell fatso- "I think you are losing weight".. And perhaps he will make some attempt at losing weight..

8) For only a few genes play a big role..

9) Unfortunately this might bea topic for comic relief!!

10)Who wants to split a special pizza??

11)Also humans dont do well with scare tactics eg. "you will die of coronary artery disease"

 

[Sparda29]

The thing with me and the Atkins diet was, at the same time, I just started a job working at a school cafeteria, and they basically had me doing janitor work, which is actually decent exercise. On top of that, I was working out 4-5 times a week at the gym, with power training. I lost 35 pounds and went from a 39 to 33 waist.

Went back to school, and lost ability to consume protein (since I'm Muslim, I can't just eat any regular beef/chicken, I can only eat the stuff that is slaughtered and prepared by Muslims, and since you can't guarantee that, I went back onto an all-carb diet while I was away from home.

 

[Tired]

If you maintain the same level of activity, but but out 500 cals per day, you'll lose one pound per week.

I assume you're using a rough calculation along the lines of how many calories are in a pound of fat, and how much you lose by cutting out those calories. I think your math is probably off a little though, since when I calculate it using your 500 calorie diet, I get about 2-3lbs (1 pound fat = 7600cal).

In general, the rule of thumb is that 2lbs of weight loss per week is "safe" and "healthy".

But as a practical matter, people who are obese are actually expending huge amounts of energy to maintain their basic bodily functions (cardiorespiratory, ambulation) with their excess weight. Their "daily caloric requirement" at that weight is significantly higher than that of a normal weight individual.

What you see with obese people who actually go on and stick to a restricted calorie diet coupled with an exercise program is that they lose far more than 1-2lbs per week (just look at Biggest Loser to see what I'm talking about). And this is very safe.

To note though, 500cal per day is a very restricted diet. Very restricted. Most people can't maintain that, and honestly, I wouldn't really recommend it, especially just starting off.

 

[howelljolly]

Why am I thinking that a pound of fat is 3500 cal.....?

Thats true though, all that extra human needs to be vascularized and oxygenated. And the problem becomes, what needs to go first - the extra tissue, or the nutrition to said extra tissue. So, we feel pretty lousy when we are on a diet.

I was going to mention that keeping a 500 cal/day deficit is very difficult, but I didnt want to admit that. 500 calories is almost a small meal.

For people like us, I think the "small frequent feedings" diet is good. Six small meals, all heathy (oatmeal, fruit, turkey on wheat, yogurt, light dinner, and a snack), and never full, and never hungry all day.

And, exercise an hour a day, five times a week.

Now if only I could stick to that.

 

[87138]

I assume you're using a rough calculation along the lines of how many calories are in a pound of fat, and how much you lose by cutting out those calories. I think your math is probably off a little though, since when I calculate it using your 500 calorie diet, I get about 2-3lbs (1 pound fat = 7600cal).

In general, the rule of thumb is that 2lbs of weight loss per week is "safe" and "healthy".

But as a practical matter, people who are obese are actually expending huge amounts of energy to maintain their basic bodily functions (cardiorespiratory, ambulation) with their excess weight. Their "daily caloric requirement" at that weight is significantly higher than that of a normal weight individual.

What you see with obese people who actually go on and stick to a restricted calorie diet coupled with an exercise program is that they lose far more than 1-2lbs per week (just look at Biggest Loser to see what I'm talking about). And this is very safe.

To note though, 500cal per day is a very restricted diet. Very restricted. Most people can't maintain that, and honestly, I wouldn't really recommend it, especially just starting off.

I've always been taught 1lb of fat is roughly equal to 3500 calories. And I assumed (perhaps erroneously) that the other poster was talking about CUTTING OUT 500 calories a day compared to whatever they were consuming on average (which would equal a 3500 calorie net deficit per week), and not actually just consuming 500 calories a day (which as you said is extremely unsafe in the large majority of situations).

 

[howelljolly]

Oh bother...

Yes, the 500 cal/day deficit is taken away from what you are normally eating.
If you normally consume 2000 calories daily, you'll need to restrict yourself to 1500 cal/day. If you are used to 2500 cal/day, you should take only 2000 cal/day. And so on.

If you take 500 cal/day less than usual, you'll have 3500 calories less at the end of the week... equating to 1lb of fat (i think)

 

[WellWornLad]

So yeah, what I meant by diet and exercise is that it works in theory and when the subject is controlled, but just telling someone to diet and exercise without fixing their dietary and exercise habits isn't going to accomplish anything.

Physicians aren't parents, and they're not superheroes who can rescue you from yourself. They can't be expected to "fix" people's problems if the patients don't comply of their own free will.

If you don't know how to eat well, go see a nutritionist (or have your doctor give you a referral, as they are apt to do). If you don't know how to exercise, go find a personal trainer. If you want a boot camp/Biggest Loser intensive weight loss program, I'm sure there's someone out there you can sign your life over to for a few months. If there are no sidewalks in your town, and only fast food joints at every corner, go talk to your city council or government representative and see what can be done. None of these jobs really fall into the job description of your average PCP.

Seriously, what does the OP suggest that doctors do to "fix" people's habits, beyond recommending that which is best for them?

 

[alex999]

See the thing with "The Biggest Loser" is that the participants are pretty restricted on what they eat and are pushed to the limit by the trainers during exercise. When I go to the gym, I don't even do 50% of what they do on that show. Their diet is also tightly controlled and access to bad food is pretty much cut off. No wonder they lose weight, they have like a 3000 caloric deficit every day.

So yeah, what I meant by diet and exercise is that it works in theory and when the subject is controlled, but just telling someone to diet and exercise without fixing their dietary and exercise habits isn't going to accomplish anything.

the treatment for obesity is diet and exercise just as the treatment for diabetes is insulin . Using your logic insulin is only treatment in theory because you can't make the patient take the medicine.

 

[Sparda29]

Physicians aren't parents, and they're not superheroes who can rescue you from yourself. They can't be expected to "fix" people's problems if the patients don't comply of their own free will.

If you don't know how to eat well, go see a nutritionist (or have your doctor give you a referral, as they are apt to do). If you don't know how to exercise, go find a personal trainer. If you want a boot camp/Biggest Loser intensive weight loss program, I'm sure there's someone out there you can sign your life over to for a few months. If there are no sidewalks in your town, and only fast food joints at every corner, go talk to your city council or government representative and see what can be done. None of these jobs really fall into the job description of your average PCP.

Seriously, what does the OP suggest that doctors do to "fix" people's habits, beyond recommending that which is best for them?

Well, if I was the physician, I would have looked up some dietitians and physical trainers for the patient, but he didn't even do that.

 

[howelljolly]

Either obesity is due to a pathological process, or its not. If it is not, then it isnt really the in the physicians scope of care. The thought that it is due to pathological metabolism and genetics and such has only come about recently. So, plenty of old time physicians might not manage obesity for that reason. A more recently trained physician may be apt to do so.

Just as some physicians do not address minor psychological issues because they consider them to have a "bad attitude" or something, others may have the same ideas about obesity.

 

[montessori2md]

In my clinic, how an MD addresses wt loss depends on how they "read" the pt -some people seem interested, and some don't. I think those who seem interested get pretty decent advice -the clinic offers classes on diet and exercise in house at least once/month, taught by an NP.

I think it's important as a doc to at least point out to folks that their lifestyle is risky, just as if you would to a pt who admitted to having lots of random unprotected sex, etc.

We have been nagged frequently about the dangers of "metabolic syndrome" and had a crash course on how to counsel pts on lifestyle changes, complete w/ psychobabble and practice formulating "reflective statements".

A lot of my pts live nowhere near a real supermarket, and subsist mostly on processed junk, b/c transportation is a problem (can't get fresh food if you go to the store/food bank once every 2 weeks).