Wednesday, December 17, 2014

The Nutrition Debate #271: Treating Obesity Today

Among the myriad missives that arrive in my inbox daily are offers of Continuing Medical Education (CME). This half-hour video (with transcript) from Medscape LLC is worth 0.50 AMA PRA Category 1 Credits and was supported by an educational grant from Takeda Pharmaceuticals and Orexigen Therapeutics (drug makers).  “This activity,” Medscape says, “is intended for primary care clinicians, endocrinologists, diabetologists, and other allied healthcare professionals who manage patients who are obese.” I am always interested in how the medical profession manages to mangle this subject, so I watched it.

“The goal of this activity,” Medscape avers, “is to focus on the global public health crisis of obesity and to demonstrate how motivational interview techniques can be used by clinicians to help patients who are overweight or obese establish a partnership with their clinician and foster patient adherence to an individualized weight loss management plan.”

To recapitulate, here’s the plan: Scare the patient with the obvious – the prevalence of obesity and its unhealthy consequences and co-morbidities; then, if they are ready, help them by using “motivational interview techniques.” Do this by “partnering” with them to “foster” adherence and develop an “individualized weight loss management plan.”

Motivational techniques can help, I suppose, but “public health statistics” wouldn’t motivate me. Besides, everybody already knows that. The key is the patient has to be of a frame of mind to be ready to 1) personally want to try (again) to lose weight, and 2) the patient has to have a level of confidence that the weight loss plan will work. The two critical points are 1) “are you ready?” to lose weight and 2) the weight loss plan itself. It’s a critical one-two combination punch.

That being said, some of the questions the video posed to assess the motivational readiness of the patient were good. Absent the readiness on the part of the patient before the interview, this type of questioning might be fruitful.

     How important to your health is getting your weight under control?

     What is your biggest barrier to losing weight?

     What do you think you could do to lose weight?

     How confident are you in your ability to lose weight?

So, whether you come to your doctor’s appointment already motivated (as I was – see the penultimate paragraph of #260), or whether your doctor thinks he cajoled you into trying to lose weight again, the key is having a level of confidence that the weight loss plan you follow will work. This is where the video fails miserably and utterly to produce a knock-out punch. In fact, I would say the medical doctor who gave this advice should never even have put on gloves and gotten into the ring.

The match started to “go south” when in response to “what do you think you could do to lose weight?” the video suggests “exercise” and “eat smaller portions.” And instead of “eating a lot of high calorie foods” (that would be fat, right?), the doctor prompts you to “eat more vegetables” (all carbohydrates!). This doctor may know something about “motivational techniques,” but he clearly knows nothing about effective (“efficacious” in pharmaceutical- talk) weight loss plans.

He suggests seeing the patient once a month for 6 to 12 months to “create a partnership” and “foster adherence” to the “individualized” plan that you formulate together. He also suggests using this time to “direct the patient in the direction you’d like them to go.” And there’s the rub. All clinicians who treat the overweight and obese know that that so-called “individualized” direction – to “exercise more, eat smaller portions, eat less fatty food and more vegetables,” is doomed to fail. Their patients are going to be hungry all the time. They are not going to lose weight or keep it off. (What do they think you’ve been trying to do all this time?)  So what then? Weight loss drugs? Hmmm… I’m beginning to see the value of pharmaceutical companies providing “educational grants” so that, if all else fails, having “fostered” a relationship, you can “partner” the patient “in the direction you’d like them to go.”

“Upon completion of this activity,” Medscape says, “participants will be able to:

1.       Identify health consequences of untreated obesity and its association with the development and progression of comorbidities.

2.       Translate techniques of motivational interviewing to increase provider-patient discussions regarding obesity management.

Okay, I got the “scare the patient” part. It’s the “translate” part that doesn’t work for me. “Drug speak” is not the way to manage obesity. Nutritional counseling to cut out carbohydrates is, however, an effective weight loss management plan.


  1. When I see how miserably the medical world fails on something as simple as diet, it makes me question how they treat everything. I followed up my appointment with a dietician, where I got absolutely nothing but the common line "eat a balanced diet, small portions, etc. doo dah" by emailing her Franziska's latest blog entry. I said, "this is the sort of information I was hoping to get from you." Her reply? "Well, you know that information is controversial." Low carb, high fiber? Controversial? Only in the insulated world of professional medicine, where no one seems to have read anything since 1955.

    Once again, thank you for being out there bringing attention to these things.

    1. Thanks, Jan. YOU are my favorite and most supportive reader. I would write this column JUST for you, knowing how it supports this WOE for you, but of course I know it supports others as well who are just not as voluble.

      I have a good relationship with my NYC doctor (the one who inherited me when my primary died), but I have to remind him that the reason I go to see him is to get my blood tested 3X/yr. This month I found myself in his office AFTER both the nurse and he had seen me and realized she (the nurse) had not taken blood!

      I told hime the tests I wanted to have done, and he said, "You mean you want to have them done today?" Then he wrote down the things I wanted tested, and when the report arrived he had NOT done a complete metabolic profile, nor a CBC (which on his last report he wrote "retest on next visit" or a TSH, free T3 and free T4 (although they did do a reverse T3 as requested. (I actually think the problem is the nurse, who is very good but a little too independent. She's been with him a long time.)

      Anyway, on the report he wrote, "Glucose intolerance; Diet, exercise, weight loss." Thanks a lot!

      But what's a doctor (or a nutritionist) to do these days. They are hemmed in by Medicare rules, the AHA/ACC/ADA/AMA, and now the ACA ("Obamacare"). That's why if we diabetics want to be healthy, we need to take charge of our own healthcare, and continue reading and learning and reading...