Thursday, November 14, 2019

Retrospective #271 Treating Obesity Today

Many messages appear in my inbox daily, including offers of Continuing Medical Education (CME). One half-hour video from Medscape, supported by an educational grant from Takeda Pharmaceuticals and Orexigen Therapeutics and worth 0.50 AMA credits, arrived recently.  “This activity,” Medscape said, “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 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.”
Here’s how I would rephrase that: 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; failing that, having obtained their confidence, prescribe a drug.”
Motivational techniques can help, I suppose, but “public health statistics” wouldn’t motivate me. Everybody knows that being fat is unhealthy. The key is the patient has to be ready and willing 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) will the plan work? It’s a combination one-two 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, 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 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, and their patients, 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 if they do, 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 why the pharmaceutical companies are providing “educational grants” so that, if the doctor’s efforts fail, having “fostered” a relationship, he or she can “partner” the patient “in the direction ‘you like them to go’.”
So, remember the two key components: 1) The obese patient has got to want to lose weight (that’s easy), and 2) the weight loss management plan has got to work. Both you and your doctor know that “exercise,” “smaller portions,” and “more vegetables” does not work. It just going to lead your doctor to writing a prescription, but drugs are not the way. Cutting out carbohydrates is. It’s a very effective, permanent weight loss management plan. Why not try it?

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