At the Philadelphia College of Osteopathic Medicine, there is a wait list for an elective that teaches medical students how to cook healthy meals. Yes, they learn about nutrition and how to make healthy dishes for themselves, but there also is a patient engagement component, says Jay S. Feldstein, DO, FACPM, President and CEO of the college. “They are better able to relate to their patients and to have that conversation about weight.”
The NEJM Catalyst Insights Council Patient Engagement Survey: The Failure of Obesity Efforts and the Collective Nature of Solutions, shows that only 10% of obese patients are extremely or very engaged in addressing their weight, so clinicians do need to do better. Feldstein says the school developed the program after visiting the culinary medicine program at Tulane University. “Instead of just handing a person a diet, we can talk to them about how to cook and what to cook. We can have a meaningful conversion instead of handing someone a piece of paper. This is really about trying to emphasize preventive medicine.”
Part of the problem is that patients do not even realize the medical implications of their obesity. “If you’re a size 42 and don’t have diabetes yet you may think, ‘There’s nothing wrong with me. I’m just big.’” While behaviors such as fat shaming are increasingly rejected by society, Feldstein emphasizes that the conversation has to be about what is healthy for you. Some say that if you are overweight and exercising, you are on the right track. “That is true to an extent, but people need to understand that there are significant risk factors for being obese. Arthritis development, knees, hips, especially type 2 diabetes. We need to have those conversations earlier with patients.”
Feldstein acknowledges that physicians tend to be chief complaint–oriented, and that weight tends to fall to the bottom. But the physician does not need to be the primary clinician to address weight; it could be a wellness coach or a nutritionist.
“Obesity is a major public health threat, but you don’t see it described that way. Who is the bad guy? Is food the bad guy, or is the patient the bad guy?”
It is really hard to make it a public enemy from a public health standpoint, Feldstein says. “Losing weight is hard. Quitting smoking is hard. But you have to eat; you don’t have to smoke.”
Marjan Bahador, MD, a critical care physician with Howard County General Hospital in Columbia, Maryland, a part of Johns Hopkins Medicine, has been living in Denmark and finds that culture plays a role in obesity.
“I am coming from a different culture and have been living in the U.S. for 20 years. And at first, it was a culture of shock for me. In the U.S., you see the toddlers sitting in their strollers, with a cup holder in the stroller with a sugary colored drink that they are constantly sipping. They are not hand-in-hand with their parents and walking,” Bahador says. “The parents don’t understand the kids get used to that, sitting and drinking sugary fluids.”
Making kids active needs to start from time they learn how to walk. “I met a neighbor in Denmark and they have an 8-month-old boy who is running. At age 2, they can ride a 2-wheel bike. They become healthy because very early in childhood they are active. Denmark is an advanced country, but parents make food at home from scratch, they don’t buy ready-made foods, and there are not many fast food restaurants.”
The fundamentals of preventing obesity are awareness and education, Bahador says. “That needs to repeat itself in different parts of the person’s life in different ways for it to finally become a part of culture. We have seen fast food and their way of advertising has become part of the culture, and I think we should start a campaign, basically the opposite, bringing people back to a healthy lifestyle, good nutrition, with education for the child in the schools and for the parents with social media and other means to help people understand.”
Bahador cites two key steps. “It is important that we believe in patient-centered care, where the physicians are partners and look at the life from the eyes of the patients and help them find solutions for themselves, and then help them to achieve their goals. Second, physicians need to get beyond concerns that prevent them from discussing weight with a patient and bring it up in a professional manner.”
Michael Robertson, MD, a Chief Medical Officer at Covenant Health Partners in Lubbock, Texas, says that reversing the obesity epidemic will require action by clinicians and others to effect broader societal changes.
“Part of the problem that we have gotten into is as a society, we’ve just gotten larger and larger, we tend to be more inert, we do less in the way of physical activity, and we eat like we were still 17 years old and we had the metabolism to support it. Our choices of foods are not always very good either,” he says.
“My big concern is that we’ve got an epidemic of very young children who are obese enough that their genetic background is that they’re going to develop type 2 diabetes when they’re not even in junior high school and middle school. That’s problematic because we know that natural history of that disease, and many of those children are going to end up with coronary artery bypass in their mid-30s and renal failure at an earlier age.”
Physicians need to be better about engaging patients directly. “We tend to shy away from pointing out to people that they are, indeed, obese and morbidly obese,” Robertson says. “We don’t use those terms when we probably should; we kind of dance around it because we don’t want to hurt anyone’s feelings.” As a result, clinicians fail to help patients understand the downstream health consequences of being tremendously overweight.
But some solutions lie beyond the traditional medical setting.
“Whether you like the ACA or not, it has, indeed, helped some people get access to care, and getting access to care earlier — when you can bend the curve on a disease process — is certainly cheaper for society than waiting until that diabetic has all the diabetic complications,” Robertson says. “We’ve got to be a bit more rational and use our clout and respect to advocate with Congress to think about some of the things that they’re doing and look at it from a business perspective. How you fund it is another story altogether, but the current system — that you have to work for a big company to have insurance to have access to care — is certainly not working. People who are relying on two incomes just to make ends meet do not have $1,400 to pay for a health insurance policy.”
The health care industry is much different than other industries, so the usual principles don’t apply, he says. “We do preventive maintenance on a car or a house because we see that as a valuable asset that we want to take care of. Yet we don’t look at health care as being an asset for each individual’s body that we should do something about.”
“It would require a change in the way people think about things.”