Tuesday Jan 06, 2015
New Year Offers Opportunity to Help Patients Lose Weight
Lean in close and I will tell you a secret that Big Pharma does not want you or your patients to know. Exercise is powerful medicine.
And here is the best part: It can be practically free. Add in some dietary improvements and you have a potent combination for improving chronic conditions such as diabetes, hypertension, chronic obstructive pulmonary disease and chronic heart failure.
But how often do we start with those interventions or continue to encourage them as the cornerstone of chronic disease management? Physicians are inundated with advertisements and drug reps' spiels, as well as some professional guidelines that rely too heavily on pharmaceuticals.
Now combine a lack of specific training in exercise and diet prescription, a pinch of extra time in our already overburdened office visit and a dash of good ol' American "Can't you just give me a pill to fix this" attitude, and before you know it, the FDA is approving metformin-laced potato chips.
But it doesn't have to be this way. With a little effort and encouragement on our part -- and some patient buy-in -- amazing improvements in health can be achieved.
Take, for instance, my patient John. He is in his late 60s and moderately overweight. Shortly after seeing me as a new patient, we ordered some routine lab work and found his blood sugar to be elevated on a fasting test. I ordered a hemoglobin A1c, which came back at 10.7. I had him return to the office to review his lab results and discuss the diagnosis of diabetes. This scenario, unfortunately, plays out in family medicine practices every day.
Like many of my patients, John was not enthusiastic about having to start multiple medications. So we discussed improving his diet and starting an exercise regimen as initial treatment. Of course, I counseled him that this was no guarantee that he would not need to start medication in the future -- that would depend on how successful we were with this approach. I did start him on baby aspirin and referred him for diabetes education, mostly to reinforce what I had already told him and for more specific dietary counseling. I also made a follow-up appointment with him.
Now, it's all well and good to encourage patients to exercise, and everyone is familiar with the daily recommendations for adult activity. However, from a patient's perspective, it does no good to simply tell someone to exercise for 30 minutes a day, five days a week. That will get you a whole lot of patients who don't follow your recommendations.
If you really want to help these patients succeed, consider making your own modest investment in a resource you can use to educate them -- and yourself. The American College of Sports Medicine, for example, offers evidence-based guidelines(www.acsmstore.org) for exercise testing and prescription. I like to give my patients options for types of exercise that may work best for them. For that reason, I did not recommend that John, with his bilateral knee arthritis, start a walking program because I knew this would set him up for failure. Instead, using a recumbent bicycle or pool aerobics were better options for him.
Also, it's important to assess the patient's current level of activity and keep that in mind. A sedentary patient should not start with 30 minutes a day, five days a week. He or she would be extremely sore and give up right off the bat or even be injured. Instead, start with 15 to 20 minutes two to three days a week and work up to five days a week over several weeks.
I also calculate a target heart rate for my patients during exercise so they have a measure to determine the appropriate intensity level. I use 40 percent to 60 percent of their heart rate (HR) reserve (maximum calculated HR minus resting HR) for moderate intensity. I will often write this information down on a script so they have something to refer to or hang on the refrigerator to remind them of their goals.
Dietary counseling is much more convoluted, in my opinion, because there are so many diets out there. However, I like to encourage my patients to make small changes initially and to try to choose healthier foods and improve portion control. The problem with so many diets is that they are just not sustainable for patients because they require radical changes that are hard to stomach -- pun intended.
A meta-analysis(jama.jamanetwork.com) published recently in JAMA also found that there was little difference in weight loss with the named diets (South Beach, Atkins, Paleo, etc). My take on this is simply that many of us are subconscious eaters. We get hungry, and we eat without paying attention to what and how often we eat, our portions, and what macronutrients our food contains. To me, the true benefit of being on a certain type of diet lies not in the diet itself but in the fact that it forces us to make more conscious decisions about our food and eating habits.
Finally, education on reading nutrition labels is also important, because many people -- often through no fault of their own -- are "nutrition-illiterate."
So how did John do? At his three-month follow-up, he was eating less junk food and more fresh fruits and vegetables, and he had reduced his overabundance of carbs. He had purchased a gym membership, although he was not yet routinely going. But he felt committed to improving that and to exercising regularly. His repeat A1c was 7.1! I would challenge you to find a single medication (short of starting insulin) that would decrease a patient's A1c by that much in three months.
Needless to say, he was happy with these results, and so was I. It further encouraged him to go to the gym more regularly, and I would often see him there.
Many of our patients will be making New Year's resolutions to lose weight, and this presents an opportunity to provide counseling. Many of you likely are already prescribing these interventions, and I hope John's story motivates you to continue to encourage and counsel your patients throughout the year.
Making these changes is not easy for patients, and although it often feels as though our advice is ignored, I promise you that you are making a difference. When they are successful with these changes, I would encourage you not to be afraid to decrease or stop their medications. After all, with the potent new "medication" you are prescribing, they may not need the pills.
Peter Rippey, M.D., is working locums while transitioning from private practice to a hospital-employed position.
Posted at 11:44PM Jan 06, 2015 by Peter Rippey, M.D.