Physicians key to winning fight against fat

Honolulu -- Just before the Obesity Action Workshop at last month's AMA Interim Meeting a doctor approached Melvyn Sterling, MD, to express his frustration that nothing he did seemed effective in helping patients manage their weight.

Dr. Sterling, the forum moderator and an internist from Huntington Beach, Calif., was not surprised. He explained later that his colleague's comment illustrates the struggle doctors face in trying to deal with obesity. They don't think there is much they can do. And their hopelessness is so pervasive that numerous studies show they often don't even ask patients about their weight.

"Obesity is absolutely the most difficult challenge in my practice," said Dr. Sterling, chair of the Council on Scientific Affairs. "But there are some things that work."

Still, Dr. Sterling, workshop panelists and audience members acknowledged that most of the interventions have limited effectiveness, but they didn't concede defeat. Their message was that there is much medicine should try to do to turn the tide.

"There's a lot that needs to be done regarding treatment efficacy, counseling skills, and reimbursement, but there is no question that we are sitting on the most serious threat to our nation's health, and we must rise to the occasion with whatever tools, resources and strategies we have available," said Robert Kushner, MD, a panelist and medical director of Northwestern Memorial Hospital's Wellness Institute in Chicago.

For starters, many doctors wait too long to mention an obvious problem.

According to several studies presented at the meeting, nearly all physicians will discuss weight with a morbidly obese patient but far fewer broach it at the earlier stages. A study in a 1997 issue of Preventive Medicine found that only 18% of physicians were likely to bring up weight issues with patients who were overweight. That number goes up to 42% for mildly obese patients and 94% for those who are severely obese.

"There's a very high threshold for a doctor to say something," said Dr. Kushner. "We need to get doctors to identify and screen early because it's a lot easier to prevent obesity than treat it."

Creative strategies

Ideas mentioned that do seem to help patients include recommending pedometers to measure how much a patient is walking, subtracting the same number of dollars from a patient's bill as pounds he or she lost and hosting special lectures for patients to learn about nutrition and fitness.

"Pedometers work," said Dr. Sterling. "They're cheap. They are a terrific way of motivating patients and giving them positive feedback all day long."

The physicians also agreed that even limited progress -- a loss of five pounds -- was a very positive step and worth the effort. Patients would be thankful, and physicians would not always feel like their interventions were in vain.

"It requires a tremendous amount of focus, and success is dependent on having the right kind of patient at the right time in their lives and the right kind of help," said Dr. Sterling. "In my own practice, I've had some really notable successes, and patients are grateful if I help them lose weight. They're not as grateful if I lower their blood pressure or cholesterol."

But physicians said there were many barriers, even when treating a motivated patient. Many have unrealistic expectations about how much weight they can or should lose and how fast the pounds will come off. Insurance reimbursement is always shaky, and patient motivation is tough to sustain over the long term. Also, physicians may themselves be overweight, causing them to be uncomfortable introducing the subject.

"There are a lot of obese doctors. Maybe that's why we're not addressing it" said Mahendr Kochar, MD, an internist from Brookfield, Wis., who attended the session.

Experts also said, however, that doctors have a role outside the office. Physicians can work to make their communities more conducive to maintaining a healthy weight. This task includes advocating for healthy snacks in vending machines and being vocal supporters of efforts to make exercise an easier option.

"I challenge all of us to look at what communities can do, and how we can incentivize people to exercise," said Mary Anne McCaffree, MD, a pediatrician from Oklahoma City who participated in the workshop. "Think about it -- what if the [hotel we're staying at] charged us a lower rate for using the health club instead of charging us more."

Physicians also have an increasing number of resources to turn to for assistance. The U.S. Preventive Services Task Force issued recommendations in December that all patients should be screened for obesity and patients who are obese should receive intensive counseling and behavioral interventions. And, in recent months, both the American Medical Association and the American Academy of Family Physicians have released practice guidelines for the treatment and diagnosis of obesity and overweight.