Primary Care and the Obesity EpidemicPrint This Post
Treatment of obesity and obesity-related conditions costs billions of dollars a year. In 1990, the direct cost of obesity-associated disease in the US was $45.8 billion, and the indirect cost of obesity was estimated to be an additional $23.0 billion. By 2005, the U.S. spent $190 billion on obesity-related healthcare expenses. Looking ahead, if these trends continue, by 2030 obesity-related medical costs could rise by up to $66 billion a year. The sheer size of this economic burden and the huge toll that excess weight takes on health and well-being point to the obvious – individuals and their clinicians must do more to stem the rising tide of obesity.
Our focus has shifted. It is no longer sufficient to treat illness and disease; we must strive to prevent it. The American Academy of Family Physicians (AAFP) and the U.S. Preventive Services Task Force (USPSTF) have recently recommended that clinicians screen all adults for obesity and offer a multi-component behavioral intervention program.
In my office, I guide my patients in their personal journeys toward optimal health. Outside the office, I guide other clinicians across Georgia and the United States to shift their focus from reactive medicine to preventive medicine.
Diet and exercise alone are not sustainable weight-loss tools. Exercise and caloric restriction will lead to weight loss, but such routines are difficult to maintain. This leads to “yo-yo” dieting and deteriorating health.
The key is to empower patients to become healthy, and as a side effect of improved health, they lose weight. It all begins with habit change. Change is hard, and that is why personal coaching is crucial for success. The coach can be a clinician or a certified coach. The coach need not be a dietician or nutritionist; it is sufficient that the coach have training and clinician supervision.
Coaching is a natural extension to our normal work as physicians. During the routine History and Physical portion of an office visit, I obtain a thorough diet history, inquiring first about breakfast. How long after waking does the patient eat? What is the patient eating? Does the patient even eat breakfast? Then I want to know the patient’s eating routine for the remainder of the day. Once I have this information, we are able to begin a conversation of healthy nutrition. Sometimes it is a conversation about the patient’s wonderful eating habits – but most of the time it is not.
I simply start by explaining to patients how important it is, while awake, to eat a balanced small meal of protein and carbohydrates every three hours. Then, I explain the interaction of glucose and insulin. Why, you ask? You would be amazed at the power of a simple explanation of the glucose-insulin curve. Patients understand it, and this understanding affects their nutritional choices.
As you know, the heart and the brain specifically want glucose. Even if you skip breakfast, your heart and brain still want glucose… and they will get it! They borrow it from the liver, which obliges by dumping glycogen to give the body this much needed glucose.
At the same time, the body protects itself against this glucose surge with a secretion of insulin. The insulin, in a protective manner, takes that free glucose and starts re-storing the glucose as glycogen. High insulin levels also imply starvation to the body, which encourages muscle to release the energy stored in protein in the form of ketones. These ketones are now preferred by the brain and the heart. At this point, any food eaten is now more easily absorbed into fat because the insulin level is high.
Steady, lower levels of insulin are a different story. Fat does not easily increase when insulin levels are low. Cholesterol, triglycerides, and blood pressure dramatically and quickly improve. The patient needs fewer medicines to combat these chronic conditions. The secret, then, is to keep insulin from surging.
So, how do you prevent the insulin surge? You encourage regular, small meals that are comprised of equal amounts of protein and carbohydrates. Patients in my office have the option to use portion-controlled pharmaceutical-grade meal replacements that are a perfect one-to-one, carbohydrate-to-protein ratio. And, you coach the patients so that they will maintain this plan.
Part of the secret to effective coaching is eliciting from the patients what it is that they want. They need to realize and accept their current health status, and identify a compelling personal reason to attain and maintain optimal health. Weight loss is not a compelling enough reason, though it is probably the initial incentive for a patient to improve nutrition. Eventually, though, the patient needs to identify reasons beyond weight loss, or the yo-yo dieting cycle will continue. The clinician or certified coach can help the patient to identify long-term goals and reasons for optimal health.
When you personally engage patients to take responsibility for their own health, you empower them to get healthy. (Note: You are empowering them to get healthy, not to lose weight!) And this is true not only for obese patients, but also for patients with chronic disease. This is also true for patients who are not overweight but think that they are healthy until, of course, they have a routine physical exam and find out about their hypercholesterolemia, hypertension, and pre-diabetes. In the past five years, I have taken so many people off their diabetes, hypertension, and lipid medications that my peers and pharmaceutical representatives are interested in learning my method of success.
Obviously this method takes time, but the rewards have included improved patient health and a new profit center for my practice. If there were a way to get paid by spending more time speaking to patients, is that something you might be interested in? Isn’t this the reason we went to medical school? In this era of healthcare change, expanding your profit center alternatives is more and more attractive.
Teaching patients and clinicians about optimal health has been not only extremely satisfying, but it has changed the course of my career as a family physician. Maximizing pro-active, preventive care and minimizing reactive care has become my goal and the goal of my very satisfied patients. Try it and you will be amazed at the quick, dramatic change you can facilitate in people’s lives.
Brian K. Naldolne, MD, FAAP
Published on December 4, 2012
Brian Nadolne is the current Chair of Family Medicine at Northside Hospital in Atlanta, President-elect of the Georgia Academy of Family Physicians and a Global Director for Take Shape for Life. Address inquiries to email@example.com.
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