Tuesday Aug 06, 2019
Helping Patients Lose Weight Is Hard, but Don't Give Up
How often do we feel inadequate in our ability as physicians to help patients lose weight? For me, it's almost daily.
We are all aware of the screening recommendations for patients with overweight and obesity. I spend a considerable amount of time discussing "lifestyle modifications" and creating action plans that patients agree are achievable. We review how to read a nutrition label, how to count calories or reduce portion sizes, how to increase fiber, and how to substitute healthier -- yet still culturally appropriate -- foods for the items that are contributing to an unhealthy weight. I make a point of using motivational interviewing skills, and I emphasize the need to address mental health and family dynamics to create behavioral changes.
And, of course, we talk about how to incorporate physical activity into patients' day-to-day lives. Without access to certain resources, such as an on-site nutritionist, I am constantly exploring websites and looking for other resources to determine how to best use the 15 to 20 minutes we have together to truly effect change.
With all the information we have about risk factors associated with obesity and the importance of reaching a healthy weight, the scientific community is still searching for consistent, proven methods for safe, healthy weight loss that achieves long-term results. Clearly, there are some methods that work for some patients some of the time. A handful of my patients have successfully lost weight through lifestyle modifications. The FDA has approved certain medications for use in weight management. And for some, bariatric surgery has yielded impressive results.
But with an EHR system that triggers me to discuss unhealthy body mass indexes with my patients to demonstrate my meaningful use of its presence in patient care, I am reminded at each visit that my patient has not reached the goal of a healthy BMI.
It seems there are constantly new headlines focused on how to lose weight and keep it off. Some of them reflect fads, while others are based on evidence. We know that lifestyle has a large impact on weight, that many factors contribute to who is successful in reaching and maintaining a healthy weight, and that what works for one person may not work for someone else. But we also know there are genetic and environmental factors at play that we do not yet fully understand. How do we incorporate this into our approach to helping patients lose weight?
More and more studies(www.nytimes.com) are uncovering the relationship between our genes and how easily we lose or gain weight. For example, variations in the fat mass- and obesity-associated FTO gene have been associated with increased risk of being overweight or obese. There is also the melanocortin 4 receptor gene, which is involved in the signal that tells you when you're full; when it's not working correctly, you may never really feel full (and therefore tend to overeat), or you may always feel full (and therefore tend to undereat). And there are interesting advances in the understanding of the role of epigenetics in populations of patients with obesity.(www.cdc.gov)
But many people are asking why we are only now facing this obesity epidemic. Why didn't these genetic factors play a role generations ago? And how, if we don't understand the possible genetic components, do we help our patients overcome these obstacles to reach the often-elusive healthy weight goals?
It all comes back to lifestyle. Several decades ago, our society simply ate less and exercised more. Our portion sizes were smaller, our foods were less often fried and less sugary, and our daily activity levels were higher. We didn't sit as much and we walked more. As such, those with predispositions to heavier weights from a genetic standpoint didn't have the opportunity to gain as much weight despite these genetic differences.
Human behavior is hard to change. As family physicians we know this, and we are always trying to find the kernel of motivation that will enable our patients to make the desired changes in their lives that we know can lead to healthier outcomes. It can feel overwhelming and sometimes insurmountable to consider all the variables that contribute to the status quo.
My approach is to be honest with my patients -- weight loss is hard! There are days when we make healthier choices and days when we make less healthy choices. There are factors we cannot change, such as our genetic makeup.
But we can make a commitment to each other as a team to create a plan that is tailored to their individual lives, incorporating the foods they have access to, arming them with skills to address the emotional reasons behind unhealthy choices and reviewing ways to involve their family members.
Together, we can download an app to track calories, or, for my patients who aren't adept at using apps, we talk about either creating a photo diary of their meals or simply jotting things down in a small notebook for us to review at a followup visit. When the scale doesn't budge (or when it goes the wrong direction), we talk about why, and I point out the positive aspects of what they have achieved, even if it's not measured in their vital signs.
We continue to wait for that magical, easy solution to losing weight and keeping it off, but in the meantime, we make realistic goals that set us up for success as much as possible, rejoicing when we reach those goals and regrouping when we don't.
Margaux Lazarin, D.O., M.P.H., provides comprehensive family health services at community health centers in the San Francisco Bay Area, with a focus on providing evidenced-based care for underserved communities.
Posted at 04:14PM Aug 06, 2019 by Margaux Lazarin, D.O., M.P.H.