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Adult obesity often goes undiagnosed by primary care physicians

Wednesday, April 13, 2011 | 8:22 p.m. CDT
Carla Dyer, assistant professor of internal medicine at MU, center, leads medical student Peter Dawson, left, resident physician Lance Goodall, right, and the rest of her team through patient rounds at MU Children's Hospital. Dyer teaches a course on patient-centered care at MU's School of Medicine.

COLUMBIA — Melinda Bobbitt was surprised when a friend who weighed less than she did suddenly was ordered by her doctor to lose weight; she was shocked to find out they had the same doctor.  

Bobbitt's doctor had never talked to her about her weight — more than 200 pounds at the time — qualifying her as obese, according to the Body Mass Index (BMI) guidelines outlined by the Centers for Disease Control and Prevention. 

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Bobbitt remembers thinking that her friend didn't look obese. And she wasn't; she was overweight. It was her friend's dangerously high cholesterol that prompted the doctor to discuss the benefits of weight loss with her.

“I thought it was weird that I was so grossly overweight and it was never addressed,” Bobbitt said.

The situation Bobbitt found herself in is common. Doctors generally do not diagnose obesity or discuss weight loss if a patient has no related medical conditions. According to research done at George Washington University that's included in a study called Improving Obesity Management in Adult Primary Care, 70 percent of clinically obese patients do not receive a diagnosis of obesity and 63 percent do not receive any counseling from a physician on the issue.

Because Bobbitt’s blood pressure and cholesterol were within a healthy range, her doctor never discussed weight loss with her or diagnosed her as obese.

She decided to take initiative and ask her doctor if he recommended any pill or diet supplement to promote weight loss.

He told her to give Weight Watchers a try. Instead, she employed a team approach that involved weekly weigh-ins, cooking healthy meals and watching "The Biggest Loser" with her friends. It's proved to be a fun and successful way to reshape her life and her body. 

Still, she couldn't help but wonder if a doctor's advice could have motivated her sooner, as it did her friend.  

An awkward situation

Kevin Suttmoeller, a physician and certified bariatritian at Missouri Bariatric Services, acknowledged the value of a physician-initiated conversation about weight. 

"Anytime a doctor brings something up to their patients ... it’s beneficial,” he said.

The problem is doctors want to please people and make their patients — basically, their customers — happy, he said. Weight is something people might view as a personal flaw, making it uncomfortable for both the patient and the doctor to discuss.

“How do you say that somebody is fat in a sensitive way?” said Justin DeLap. DeLap, manager of Missouri Bariatric Services, has had his own struggles with weight loss.

Having that conversation "is a tough thing to sometimes do, but it is a reality of the world we live in,” he said.

Doctors often wait until the patient has a "co-morbid" condition — a disorder or disease that occurs in addition to or because of a primary health issue — to address weight loss and manage obesity. In obese patients, such co-existing conditions include diabetes, high cholesterol and hypertension, to name a few.

“I always actually treated obesity through treating existing problems like diabetes,” Suttmoeller said of broaching the subject of weight when he worked in private practice.

When he offered his patients treatment options that didn't require medication, they were generally eager to get started, especially to avoid further complications or having to take medication. This approach seemed to help people see their obesity as a medical condition requiring treatment, not necessarily a personal flaw, Suttmoeller said.

Barriers to effective treatment

The sensitive nature of the subject matter is not the only thing that makes it tough for doctors to talk to patients about obesity.

Doctors often lack the tools they need to effectively help their largest patients; studies show that almost half of practicing physicians don't feel qualified to treat obesity.

Suttmoeller explained that in years past, medical schools just glossed over obesity. For example, when he was in school, students were not taught to calculate BMI, now a widely used measure of one's weight-to-height ratio. BMI provides a general indicator of body fatness and weight categories that could lead to health problems.

"For many doctors, the extent of their knowledge or training is just: eat less, exercise more," Suttmoeller said. Both Suttmoeller and DeLap noted that a recommendation like that for an obese patient is worthless.

In fact, DeLap said, it's discouraging.

It takes a team approach — requiring the expertise of many different types of doctors, such as dietitians and bariatric specialists — to come up with an effective diet and exercise plan based on each individual's situation, the doctors said.

Primary care physicians often have only 15 to 20 minutes to see each patient for a general checkup, Suttmoeller added. That time constraint makes effectively approaching such a complex topic unrealistic.

Doctors and patients also encounter problems with getting insurance companies to cover necessary services for those diagnosed with obesity.  Suttmoeller said he doesn't know of any insurance companies that pay for treatment if no co-condition is also diagnosed; at Missouri Bariatric Services, insurance companies can only pay staff dietitians if a patient has diabetes or kidney failure.

In the U.S., patients have to be morbidly obese before they can be considered for treatment such as bariatric surgery. And while insurance companies will generally cover the surgery that a patient needs, they typically require six months' supervised weight loss with a doctor prior to the operation. The weight loss program, whatever it might be, is not covered for patients without co-existing conditions like diabetes.

Addressing the growing problem

During the past 20 years, there has been a dramatic increase in obesity in the U.S. In 2009, more than 20 percent of the adult populations in all states except Colorado and the District of Columbia were obese, according to an obesity trend report from the CDC; in nine states — including Missouri — that rate was more than 30 percent.

Doctors are recognizing that treatment approaches must respond to changes in the nation's health to be most effective for their patients. 

Jill Bosanquet, a family physician at University Hospital, discussed this issue's importance with fellow doctors at her Feb. 23 seminar on "Managing Obesity in Primary Care."

Patients view their doctors as experts, she told the group of about 25 physicians. Primary care physicians are a person's first point of contact with the medical community, which gives doctors the opportunity to be an important first step down the road to effective treatment and proper care. Bosanquet discussed research showing that patients with a diagnosis and support from their doctors are more likely to try to lose weight on their own than those without. 

People often need an authoritative figure — like a doctor — to talk to them before they realize they have a problem or become motivated enough to address it. 

"The big challenge is getting people to shift the way they think about this problem," DeLap said of both doctors and patients. 

Obesity can no longer be thought of as the unfortunate result of a personal choice that can be simply undone by eating less and exercising more, DeLap said; it is a product of the environment we live in.

Medical schools have responded to this need for a shift in thinking by changing curricula.

At MU, for example, medical students learn about obesity from more than just a scientific standpoint; they also receive feedback on simulations they do interacting with patients struggling with weight.

Students spend their first two years of medical school in "Introduction to Patient Care," taught by assistant professor Carla Dyer. The course teaches students how to be patient-centered in their interactions with all patients; since many future patients might be obese, how to treat and talk about the diagnosis is now a fixture of the course.

Suttmoeller regularly lectures medical students — and practicing physicians — on methods for talking to patients and treating their obesity-related health concerns. His lectures include discussions of the effectiveness of medications, weight-loss plans, behavior modification and surgical options.

Changes in training programs for both future and current physicians reflect an acknowledgment of the ever-growing number of obese patients they'll treat in coming years — a number which shows no sign of slowing.

Obesity trends are expected to continue their dramatic increase with an estimated 1.35 to 2.16 billion obese adults worldwide by 2030, according to studies done by the U.S. National Library of Medicine; another study concluded that programs for prevention and treatment of obesity must become a public health priority.

"Physicians are keenly interested in how to help their patients right now," Suttmoeller said. "Especially regarding weight loss."


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Comments

Robin Nuttall April 14, 2011 | 2:13 p.m.

Unfortunately for physicians and patients alike, the BMI is really not a good indicator at all of overall health or even obesity or lack of same. The BMI looks at two things. Height and weight. That's it. It does not take into consideration age, frame size or (very importantly) muscle mass.

As an example, a lot of body builders with extremely low body fat show as "obese" or even "morbidly obese" on the BMI because they carry a lot of muscle weight. But the BMI only sees weight as weight.

It can be extremely frustrating to have a doctor come into a room and say, without actually looking at you or asking your activity level (or doing a true body fat measurement) "well your BMI says you're obese, you really need to lose weight."

Then there's the whole healthy weight range. There are a bunch of different ones out there, and frankly none of them are really based on solid science.

The real problem is actually trying to rely too much on simplistic numbers instead of examining and dealing with the patient standing in front of you. Physicians should ask about lifestyle, eating habits, exercise. They should do frame measurements and if possible body fat measurements. Don't just say "your BMI says you're obese, you need to lose weight."

Here, by the way, is a very interesting album of photos of the BMI standard applied to real people.
http://www.flickr.com/photos/77367764@N0... (or, if that link doesn't come through, do a search for illustrated BMI).

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