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Stalemate, Stout, and Stalwart in the Battle of the Bulge

By Rich Joseph
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Earlier this week the CDC reported that obesity levels have plateaued over the past few years. In 2012, about 34.9% of the people in this country were obese as compared to 35.7% in 2010. While some may take solace or even rejoice in this news, I can’t help but be cynical in thinking this is really not something to celebrate. This is sobering reminder that we're not seeing a change in adult obesity. The fact remains that nearly one third of U.S. children and about two thirds of U.S. adults are overweight or obese and therefore at increased risk for hypertension, diabetes, and musculoskeletal disease. Despite new campaign efforts, increased awareness among health care providers, and increased attention in the media, we are unable to budge the bulge and obesity remains a massive problem (pun intended on both counts).

Whether or not obesity itself is, in fact, its own disease entity is a topic for another day, but the fact that it increases the risk of numerous chronic illnesses is indisputable. And the fact that the health care system is in no way optimally equipped to manage obese patients is also indisputable. Tackling obesity requires engagement with the social, economic, and psychological determinants of health in each and every patient. Instead we take a piece meal approach in bandaging the chronic sequelae of obesity with medications and surgery.

Of course, given the multitude of factors at work in the obesity epidemic, there is no one group on whom to place the blame. With regard to health care providers, there are multiple financial forces and time pressures working against coordinated care and counseling for the obese patient. Not only is it more profitable to prescribe a pill or do a tummy tuck, but it is much easier both time-wise and emotionally than motivating someone towards weight loss. Behavior change is the holy grail of health care in the 21st century and given the circumstances of health care today, it remains largely elusive. It is not a fix that the doctor can prescribe, but rather it relies on the willingness and compliance of the patient—a surrender of control than many who desire to heal have difficulty accepting and attempting. However, most doctors are truly caring people with a desire to help their patients towards health and wellness. One major problem is that they lack the skills and practice to do just this.

Medical education is entirely outdated in that it does not teach how to best manage the lion’s share of today’s health burden—obesity and related chronic illnesses—that are crippling our nation’s physical and fiscal health. By and large, physicians lack the necessary skill set to motivate, encourage, and act as health coaches in partnership with patients. In a perspective published in the New England Journal of Medicine last week, researchers argue that part of the blame for the obesity epidemic lies with the way physicians are trained (1). Weight, specifically overweight, is not a topic breached in medical school, and therefore it is not on our radar as a crucial vital sign. A 2005 study of doctors-in-training found that only a small percentage even noted obesity in heavy patients’ medical histories, indicating that weight was not a priority in assessing their health (2). And while many of us can recognize overweight when we see it, probing the root causes of that overweight is akin to opening Pandora’s box…

“Information overload! Find quick fix and abort mission.”

Now finished with the preclinical portion of my medical education, I can speak to this. In total, I received approximately two hours of training in nutrition. And when I say nutrition, I mean research nutrition—a bombardment of results from studies that focus on one micronutrient and forget the rest of the food and the people who consume it. Unhelpful to say the least. I filled out a few online modules (that I could repeat over and over again until I received a passing score) and then moved on with my life, feeling completely inept at addressing dietary and weight management concerns with future patients. And this is coming from someone who has already invested countless hours reading about the latest trends and evidence in nutrition and fitness. I feel particularly bad for many of my classmates who will get questions from patients wanting to lose weight, and will have no idea how to address these concerns. And exercise prescriptions? The American College of Sports Medicine exercise recommendations (3) are nowhere to be found in our curriculum, nor are they asked on National Board Exams, so why would we bother learning them? There are already enough esoteric minutia to memorize, so I certainly cannot blame my classmates for turning a blind eye to lifestyle factors, even though they have greater relevance to the diseases and comorbidities they will encounter in practice.  

Despite my persistent frustrations, there are glimmers of hope and the tide is beginning to turn.  More medical education programs are incorporating what’s called motivational interviewing techniques into their curricula. This strategy helps doctors ask more effective questions to elicit meaningful answers from patients about what factors are contributing to their lifestyle choices, their attitudes towards change, and next steps towards progress.  At the University of California San Francisco School of Medicine, first year students are encouraged to educate elementary and high school students about nutrition and physical activity, and the health consequences of obesity. In real-life clinical settings, students hone their interviewing and relationship skills in discussing the delicate issue of weight with patients. Finally, sessions on cultural competence and diversity in many medical schools are providing a deeper understanding of the social contributors to health, including socioeconomic and ethnic influences, which are powerful factors in diseases like obesity.

Yet as we layer on more and more elements to medical training, we must not forget that more work does not always translate to more skill and better outcomes.  Indeed, the workaholic culture of medicine is often antithetical to health itself as evidenced by the high rates of physician burnout. Numerous studies have shown that “soft skills” like compassion, empathy, and communication—those exact skills needed to encourage behavior change—have been shown to diminish over the course of medical training (4,5). Hence, a core component of preclinical medical education should be empowering students to achieve balance in order to preserve their own sense of “humanness” in what is a humane calling. Pursuing balance and practicing wellness, which encompasses anything from exercise and cooking to spiritual practice and the arts, sharpens the relevance of health promotion for our patients.  Doctors can be models the behaviors we desire in our patients. The physician who leads a fulfilled and balanced life is more likely bring a more preventative and integrative approach to patient care. Perhaps then we can shift the gears of that drive obesity from neutral into reverse.

1. Colbert JA, Jangi S. Training physicians to manage obesity--back to the drawing board. N Engl J Med. 2013 Oct 10;369(15):1389-91.

2. Ruser CB, Sanders L, Brescia GR, Talbot M, Hartman K, Vivieros K, Bravata DM. Identification and management of overweight and obesity by internal medicine residents. J Gen Intern Med. 2005 Dec;20(12):1139-41

3. Garber CE, Blissmer B, Deschenes MR, Franklin BA, Lamonte MJ, Lee IM, Nieman DC, Swain DP; American College of Sports Medicine. American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011 Jul;43(7):1334-59

4.  Chopra SS, Sotile WM, Sotile MO. Physician burnout. J Am Med Assoc 2004;291(5):633

5. Hojat M, Mangione S, Nasca TJ, et al. An empirical study of decline in empathy in medical school. Med Educ 2004;38(9):934-941

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  1. julia frank

    I completely agree. We still teach students as if the sole purpose of interviewing is to make a diagnosis--an approach irrelevant to most visits for chronic conditions,not just weight issues.

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