Medical school trains us to deal with a wide range of medical problems.
No matter what our current practice or specialty, at some point during medical school we will have had to study and demonstrate our knowledge and competency in dealing with common disorders like diabetes, hypertension, depression, chronic pain and countless other ailments. In addition, we will have spent hours poring over much rarer disorders, conditions that many of us may never see in a lifetime of practice.
We will also have learned that obesity is a common risk factor and that many conditions could be prevented or will substantially improve if patients just lost weight. We will have been told that weight management is really a simple matter of “energy in and energy out” and that eating a healthy diet and regular exercise is all it takes to prevent or regain a healthy body weight. As a recent graduate, we may have heard of molecules like “leptin” or “ghrelin” but we will likely know far more about calcium or potassium homeostasis than about the complex psychoneurobiology or endocrinology of ingestive behavior.
In our first years of practice we will quickly learn that bringing up the topic of excess weight will either meet immediate resistance or simply open up a can of worms that will take up more of our time to deal with than we intended. We will also note that our well-meant advise to simply eat less and move more will be often met with skepticism or outright hostility and we will soon enough experience that despite our efforts, the majority of patients will either not lose weight or simply lose a few pounds only to regain them in due course.
But we continue to believe that if only our patients could deal with their weight, our life (and theirs) would be so much easier. Indeed, we will have seen the remarkable resolution of diabetes, hypertension, fatty liver disease and sleep apnea after bariatric surgery, but surely we cannot be referring half our practice to a surgeon.
At this point, we happen to learn of a colleague setting up a bariatric practice that specializes in weight management and we are more than happy to refer our most severely obese patients to her. As the load falls off our chest we breathe a sigh of relief, “Thank God for Obesity Specialists – yes, there should certainly be more of them around!”
But here is the problem. Obesity currently affects one in four adults in North America. Even if we assume that a small proportion of patients who meet the BMI criteria for obesity may be metabolically healthy, it still leaves us with tens of millions of people with excess weight. No one realistically expects that preventive measures will reverse this epidemic in the foreseeable future. So simple math will tell us that there is just no way that every obese patient can possibly have their weight issue managed by a specialist. Perhaps, the emerging field of bariatricians can see a minute subset of our heaviest patients, but those legions of patients with BMIs of 30 to 40 will remain in our practice – for us to deal with the best we can.
Fortunately, despite popular belief (amongst physicians), obesity is not a difficult or time-consuming condition to manage. Once you apply the simple rules of chronic disease management (regular self-monitoring, realistic targets, patient education) and deal with the most common obesogenic promoters (e.g. depression, binge-eating disorder, ADHD, chronic pain, obesogenic medications, etc.) you can at least halt the progression of weight gain in a substantial number of patients – a first step in dealing with any chronic progressive condition.
Simply hoping that we will one day have enough obesity specialists to take these millions of patients off our hands is both unrealistic and unnecessary – realistic weight management goals (weight stabilization – 5-10% weight loss) are both achievable and sustainable with little more effort than it takes to manage other chronic conditions – not all patients will do well – but many will. For those who don’t, a dose of empathy based on the recognition that they are up against one of the most difficult health problems of our times can work wonders.
Arya M. Sharma is a Professor of Medicine at the University of Alberta who blogs at Dr. Sharma’s Obesity Notes.
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