The problem with obesity counseling

Recently I have become interested in the obesity epidemic plaguing our country. I’ve actually been interested in obesity and co-morbid psychiatric illness since residency, but recently my interest has been revived. I read that Medicare is going to be reimbursing health care practitioners for obesity counseling and screening. My initial thought was that this is a positive step in the right direction. But the cynic in me began to wonder–what does obesity counseling exactly consist of? Who will be administering this counseling? Will it be nurses, doctors, nutritionists, or psychologists? What data is available that tells us this will actually work?

Currently, the art of “counseling” is already in danger of becoming an extinct entity, as a result of changing insurance reimbursements, which tend to be better for psychiatrists who prescribe medications rather than psychotherapy. This has influenced the state of psychiatry training programs, which have begun to deemphasize training for therapy, favoring instead a focus on psychopharmacology and biology. This has its pros and cons, as with anything, but has turned psychiatrists partially into pharmacists. I find it unfortunate.

But back to obesity counseling. Usually now, when obese patients see their doctors, they hear a lot of the same information over and over again–that obesity leads to hypertension, diabetes, strokes, heart attacks, shorter life expectancy, and so on. To deal with obesity, patients are told to eat healthier and to start exercising. Well, no kidding! All of this information is now readily available anywhere online and is not news to people. So what makes doctors think that repeating this information will all of a sudden get a patient to lose weight? It doesn’t. Which leads to no change, which in the long run, makes doctors become pessimistic, believing none of their patients will change. So they start treating the diabetes and high blood pressure, ignoring the underlying obesity, and it turns into one big never-ending cycle.

I hope this is not what “obesity counseling” will consist of. I hope that what doctors and other health care practitioners start learning is that motivational interviewing and motivational therapy is the way to get patients to start changing. We have to allow patients to tell us why they want to change, not us tell them why they need to. People only change when they are ready to. We need to start learning how to get patients to get closer to that point. It’s easier said than done.

Christina Girgis is a psychiatrist who blogs at getaheadwithdrg.

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  • Anonymous

    15 minutes of obesity counseling gets you 0.74 RVUs, just slightly more than Medicare pays for a medical assistant to take a blood pressure.

  • Chris OhMD

    Great article. As a PCP I’ve been doing “weight counseling” for a long time and have the same thoughts. We all know what to tell patients but in the end it comes down to patients changing their habits which is very difficult. In order to help change habits we have to know everything about our patients – not just medical problems and meds but their jobs, sleep habits, social life, work schedule, kids, etc - this requires a lot of time (not enough for regular office visit). This is where we can be creative – I usually hand out day/week/month log where they enter their daily activities in terms of sleep, work, social life, meds, meals in as much detail as possible. At this point I can separate those that are truely motivated to lose weight from those that are not. Once I know their daily routines on the next visit  I try to figure out what I can do to help them eat healthier and exercise more by tweaking their schedule a little at a time. I think it comes down to understanding each patient very well and knowing how to change their habits – these are very difficult tasks for PCPs.

    • Olivia Morrissette

      A patient is more likely to be on board with a physician who takes that level of interest in her health, possibly even putting some genuine effort into succeeding, partly to please her/him.   An ideal patient/doctor relationship.

  • Chris OhMD

    Just wanted to post a few characteristics of motivational therapy from Wikipedia. I’m not a psychiatrist so Dr Girgis feel free to amend:

    - Motivation to change is elicited from the client, and is not imposed from outside forces- It is the client’s task, not the counselor’s, to articulate and resolve his or her ambivalence- Direct persuasion is not an effective method for resolving ambivalence- The counseling style is generally quiet and elicits information from the client- The counselor is directive, in that they help the client to examine and resolve ambivalence- Readiness to change is not a trait of the client, but a fluctuating result of interpersonal interaction- The therapeutic relationship resembles a partnership or companionship

  • rich

    i work in a hospital where the ortho pa’s write in their consult:
    3. weight loss – this is to be coordinated by pcp.

  • Anonymous

    First:  Please forgive spelling, grammer, etc—-I was in a coma and have lost ability to see misspellings or remember how to spell or structure something: 

    I dispise doctors counseling me on obesity when the do not know the full story.  First do you think I like being fat?  Having to wear flower gardens and pop art billboards that designers think overweight people need.  Even the couture clothes are a sight to behold sometimes. No I do not like my fat.  However:  Before you counsel me–walk a 100 miles in my shoes.  I have a rare genetic mutation that negatively impacts the mitochondria and urea cycle.  I cannot process protein correctly nor can I expell nitrogen via ammonia well.  In addition this same genetic issue damages a mitochondria pathway, Complex I, Complex III and the proton pump leaving me with very limited ATP production —ATP Synthase Deficiency avg 7 to 14 —where it needs to be 36-38.   If I exercise I raise the amount of nitrogen and lower the oxygen (this causes  seisures and in my case  1 coma,and death), ammonia increases.  Ammonia is a neurotoxin so it can go to brain, cause a coma and death. We don’t even have to get to the pumps and complexes except I am also leptin resistant and the gene that is damaged is also the gene that is involved in causing fat cells to release contents (cutting).  So every-anything on the market will not help me but infact if I take could cause metabolic crisis upto coma and death.  And I cannot starve because nitrogen and ammonia go up.  I must only have 10 grams of protein and the rest is carbs or fat.  Higher level of protein raises nitrogen and ammonia —coma and death.  So tell me to execise —I am killing my self and also I will not loose weight –I just go to a metabolic crises.  One doctor told me to cut calories —another metabolic crisis. One thought he barometric surgery —that barometric doctor took one look and said we break healthy bodies —no one with any amount moral and ethical sense would touch you to break your body more than it already is.

    I sit and listing to the gripes and we need legislation for fat people.  I read bemoaning of counseling. And goodness know what information, disinformation, and misinformation they will receive to be counselors.  I am sure if I tried to tell a “couselor” –I would probably be docmented as negative does not want to do program.  My journal—I met one more medical profession who professes what is best for me without even wanting to study my rare case.  I live for the day my geneticist says we have found a way to break the lock it has on your metabolism –now you can loose weigth like everyone else eat normally. And yes I can exercise and have a shapely body. I live for the day that people receive an auto face slap for thinking a person is fat, lazy, don’t care, that there are no medical conditions that cause that yuk yuk.  No I do not want to be fat.  I would love to eat protein. I wish my metabolic system worked correctly.  I want to be able to dress sexy for my husband any time I want to without shame.  I was a beautiful size 6 when I met him.  I am lucky he has stayed.

    Medicare paying for counceling is automatically assuming that being fat is a mental problem and they can quickly fix what is broken. Maybe for some it is.  But there are a lot of us that hate it. I already go to a counselor for having a chronic, deadly disorder, that leaves my body in this bad condition and now complications of a surgery has caused more problems.  Will I die sooner?  I think the Medicare counselling thing has a more ominous objective –if you do not go and take their pills or such —your coverage will be cancelled.  There is no good intention on the counselling at all.  This is a huge plan to drop people from medical programs that they need to live.  So cut them off. Let them die.  Then they are not a drag on society.  Now the piggies who really are not sick have better access to trough.  The government will cut medical costs and we will hear someone say what a good president I am.  I want to read the mission and ultimate goals of this counselling fat people project…  Can fat people with medical conditions receive a special bat to hit some medical counselor in the head when they won’t listen.  I have 3 terabytes of research as well as 15 boxes more in paper.  I pour over research from multiple countries and have created databases culling into like areas so I will notice when the worm turns and something new is abound that may help me.

  • Anonymous

    I do disagree with the comment people only change when they want to.  I have been waiting 30 years.  Where in the heck are the advancements in the medical field that will fix the damage to my mitochondria, urea cycle, and now most recently hyperglycemia because a a possible screw up in OR.  Never give a patient with liver damage steroid IVs…..can and did cause more liver damage….

    I want to change so where are the doctors who will stop spending 15 minutes, gotta go and you see them leaving with someone for a personal date…
    Tell me where are the doctors that suffciently educated that they can even discuss my medical conditions –I hate eyes glazing over because they think this might be a hypochondriac.
    Tell me where the medical specialists that exist with an eduction sufficient to discuss multiple problems  and does not say mito what or ornithine who?
    Tell me where the people are that should be in there fighting so we patients won’t be that way —–we need more researchers.  I live in a large city —it is amazing how many buttocks leave their seats and head out for points unknown.  That  7 minutes equal to 30.3 hours of time being wasted  and patients are standing and ready.   Believe me I have to go to one of the largest medical complexes there is.  I have seen the workers in hospitals and offices and the doctors.

    The comment says change must come from the patient first ticks me off.  I have fought for years to live, have arrived at every inconceivable time day or night to be in your presence, and I scream why in the heck have you not bothered to update your eduction since the 1970-1990s.   I can show you so much published data that you should have read in your speciality and associated branches —not easy to do when you leave at 5 and don’t take calls on weekends.

    You leave the impression that all you want is money.  And if we can’t loose weight it is all our fault–we just are not ready.  Do you think I am that big of fool.  What this says is the medical field wants no accountability so it will all be the patient’s.  It is not our fault you have failed continued education courses, you take the easy continued education modules online and then go out to party.  I have studied my area so much , I can pass those CEUs with no mistakes.  For years now.

    You are wrong to fling the statement it is because we are not ready.  I am ready, but the medical industry does not have the expertise, research, and enough people to work on giving us answers.  So the problem is back in your lap I am ready —-have you studied all the things necessary and how are you going to fix me?  Fix my mutated gene?  Last time they tried that the patient died.  So what have you done to make yourself ready and not look like an arogant fool?

  • Adi

    wonder what happened with the concept of treating the patient as a whole and with
    doing the right thing for the patient?

    are guidelines (e.g. NHLBI Overweight/Obesity Treatment Algorithm, UpToDate) on
    how to address obesity for inpatients. Yet, there is a huge body of research knowledge
    suggesting that hospitals are doing a poor job when it comes to delivering
    clinical preventive services. We need to look at ways of minimizing hospital
    readmission rates, 30 days post hospital discharge mortality, and why not the whole
    hospital stay cost. Obesity it’s vicious circle. Hospitals need to act while
    the patients are still trusting the health care providers.

  • Mary Brighton

    Very unfortunate that the health professionals trained to provide obesity counseling, registered dietitians, are not included in this important subject. A major over-site by the CMS.

  • Anonymous

    I couldn’t agree more. Registered Dietitians and Nutritionists are trained to counsel patients with respect to their diet and overall health. Health insurance companies should recognize the importance of these health professionals in the treatment of obesity and start to adequately reimburse RD’s for their time. 

  • Sherry Pagoto

    Thanks for bringing this issue to light, especially the shortcomings of the CMS decision.  I am a clinical psychologist and an expert in behavioral management of obesity.  The protocols of the Diabetes Prevention Program and/or Look Ahead studies are the premiere examples of behavioral treatment for obesity.  Note that both involve 6 months of weekly counseling and then another year plus of biweekly or monthly counseling visits.  Counseling is not just advice giving, it involves a structured approach to self-monitoring, nutrition education, physical activity education, stimulus control, motivational interviewing, goal-setting, stress management, problem solving, and relapse prevention. I am doubtful any of this could be done adequately in a the context of a PCP visit— and the PCP would need extensive training in nutrition, physical activity, and behavioral modification to do it appropriately.  It is intensive therapy.  I am able to do this therapy in the medical center I work in but it is not reimbursed–the patient must pay $800 for the program, which means we aren’t treating the majority of people who need it.  The CMS decision has not helped us a bit.  Extremely unfortunate. 

  • Bonnie Nordby

    I am an RN who has struggled most of my life with obesity.  Many who have a chronic struggle with obesity have been up and down the scale many times.  We have employed many diets, exercise plans and strategies only to see ourselves regain the weight we lost and then some.  So with the reality of limited time I would employ a self administered weight and dieting history first so you can more effectively assess and relate to the patient.  Anybody know of a really good one?  A poorly done intervention can sometimes be worse than none at all.  Perhaps include a list where the patient can check off how and how not they want to counseled because that would alert you to their hot buttons.  See there are a lot of feelings of failure, humiliation and shame held by many who are overweight with levels of denial, learned helplessness, fear, anger that may show up in the room with the patient.  Above all explore your own biases and beliefs about obesity and be compassionate not just clinical.  One inexpensive follow up resource you might consider offering to some of  your patients  is Overeaters Anonymous which is a 12 Step peer support program patterned on Alcoholics Anonymous.  I have seen amazing recovery and gained so much insight and compassion and  for myself and others in this program.  Thank you to all the healthcare disciplines who take on this complex task.

  • darrick

    Not sure if this is common across the globe, but here in Singapore, obesity starts off as a stigma from young. As an obese kid, the joke will always be on him/her. Teachers in school will also discriminate and make sarcastic remarks about the kid’s obesity and physical performance. Eventually, the kid grow up with a lower self-confidence and stigma that he/she is not as good as the other (“healthy and fit”) kids. This perception continues on to adult society where the joke is always on the “fat” guy/girl. 
    I wonder if there’s any studies out there that focus on societal discrimination against obesity and better understanding of obesity (both physically and psychologically). It would be great to hear from friends globally about this issue. (P.S. I’m an obese kid since childbirth and couldn’t shed the pounds even after trying exercises and diets.)

  • Anonymous

    Until it is understood that the hugh amounts of sugar, fat and salt – layers upon layers in cheap, easily available food - are addictive, counseling is not going to do too much to change the crisis.  It is, however, going to cost taxpayers more while diabetes II and heart disease will continue to increase.  Books have been written about it!  Medical education is provided about it!

    Tobacco smoking is an addiction and it took both an increasing tax and and an increasingly strong message on the packages and then the counseling (with patches, restrictions, even embarrassment) to decrease the use.  Been there, done that!  Other countries are following this model.   Other countries are also instituting a tax on unhealthy food.  Countries that have a much lower obesity rate than the US!  The beverage companies are not going to be able to lobby them!

    It’s time to “wake up” and push back Big Food and restrict their land use for unhealthy food (corn, wheat)and stop the subsidies.  It’s time to get small farms back to grow the vegetables and fruit we need. Its time to make a bag of potato chips cost more than an apple and get the revenue to do some real counseling.   It’s more than “a soda tax” that is needed.  And it is not a sin tax (no divine intervention is needed),  it is a RISK and should be called that – on those 3 substances.  Yes, to do this is a bit more complicated than the smoking model but it can be done – we have a strong basis in the Nutrition Facts.    

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