Image from © World Obesity
I’ve been thinking about obesity almost constantly for the last three years.
A PhD will do that to you.
While I procrastinate on finishing my thesis, here’s what I’m now doing, and thinking, differently about obesity.
1. Obesity is about more than weight
Obesity is an excess of body fat alongside an impairment in health. It is not just about having a big body. Smoking as a risk factor for heart disease far outweighs the risk of a high BMI but no metabolic abnormality. Hypertension is far worse for your health than just having a high body weight. Keep high body weight in perspective – if your patient smokes, it might be better to work on that first.
2. Personal choice?
The more I read about the hormonal drivers of hunger, the brain’s reward system, and the effects of trauma or stress, the less individual choice seems to play into nutrition. Look around your community – is it any wonder it’s hard to stay a healthy weight? Write to your local MP. Pester the council about inaccessible transport and lack of public space. Petition for changes to advertising and the cost of energy-dense foods.
3. Don’t use the term obese
Obese is an undesirable term like “diabetic” and “schizophrenic”. Person-first language is the preferred way of speaking about any health condition. “Person with obesity” is the term patient groups prefer. If you see media releases or research papers with “obese” in the title, you can guess they’ve probably not been working very closely with people actually living with the condition.
4. It is possible people with obesity are not eating much
We all have patients living with obesity who swear that they are not eating much – and I now know that this is probably true. Yes, people who are living with obesity have had some period of time when their intake was more than what their body needed. But, once a person has had excess body weight for a period of time, hormonal changes occur to ensure that weight is not lost. So once weight is gained and the body identifies the higher weight as the new normal, a person can be eating not very much and the weight will be maintained.
5. Don’t cheer the scales
I find it hard to stick to this tip. I learnt from Dr Arya Sharma in Canada that we should not be congratulating patients on the numbers on the scale. Instead, congratulate any new behaviours or lifestyle changes that they have made a part of their life. This also saves the back-pedalling when you discover that a patient has lost weight through unhealthy behaviours like purging or laxative abuse. Encourage and applaud positive lifestyle change, and just take note of the number on the scales.
6. Prevention matters
A follow up study of TV’s Biggest Loser participants showed they continued to have slower metabolisms six years after the show, even after regaining all their body weight. Maintaining weight loss is hard. The body is designed to keep weight on. So when you notice a patient’s weight slowly rising, have a conversation about it early. Most of the messages in the media convince people that it is easy to lose weight and get your “summer body” back. But this is simply not true. It is so hard to lose weight, that if a patient tells you weight is falling off them with simple lifestyle changes, check for a serious diagnosis.
7. Once weight is on, a big change is needed
For patients living with obesity, particularly with a BMI over 40, big changes are needed to reduce weight and override the hormonal drivers for weight maintenance. For some patients this might include bariatric surgery – on average this results in a 20-30% reduction from highest weight point. Lifestyle changes are still the cornerstone of all obesity treatment and this is still true with patients undergoing bariatric surgery. Patients need to be carefully selected and screened for eating disorders before surgery. GPs can play an important part in the lifelong follow up that is needed after surgery.
I’ve had a paradigm shift in the way I think about obesity.
I cringe when I remember some of my misconceptions about personal choice.
But now I know more, I hope I can continue to do better for my patients.
First published on 30 November 2017 in Medical Observer (editor Jo Hartley) https://www.medicalobserver.com.au/professional-news/obesity-is-hard-to-manage-here-s-7-ways-gps-can-rethink-it