A Guide to Obesity and How to Approach the Conversation With Your Doctor
The obesity epidemic is serious but here is how you start making changes in your health.
Obesity is a difficult topic to bring up amongst the US population. We realize it’s a problem, but the stigma of calling someone “obese” persists.
When my family immigrated to the US in 1997, our bodies changed drastically. If you looked at our pictures between July through October, you’d notice a striking difference. Our faces became plump, love-handles appeared around our hips, and our bellies protruded further than before.
As I’ve progressed through my medical career, I have become increasingly aware of the difficulties that patients face when addressing weight concerns with their physicians. It’s not an easy conversation to have. Some might feel ashamed, some think that their body is naturally overweight, some just don’t see their weight as a problem for their long-term health.
Thankfully, the medical community is dedicated to ending the stigma against overweight and obese individuals. An international panel of experts on obesity issued a statement to rethink our assumptions of obese individuals as inherently lazy or suffering from low self-control. In particular, these experts mention that suggesting to “eat less and exercise more” can be triggering and damaging to an individual’s morale.
Obesity is a far more significant problem that cannot be addressed by mere diet and exercise. There are many contributors to obesity, including medication side effects, hormonal disorders, genetic abnormalities, and socioeconomic factors.
We must address this growing global epidemic. In the US, nearly 40% of the population was considered obese in 2016. A recent New England Journal of Medicine (NEJM) study projects that almost half of the US adults will be obese by 2030. We simply cannot continue down this path.
The US spends nearly 21% ($190.2 billion) of its yearly medical expenditure on obesity-related illness. The healthcare spending problem becomes even more complicated when considering the increases in disability and unemployment benefits.
How Do We Define Obesity?
The use of the body mass index (BMI) has become a widely accepted method for categorizing an obese person. Try it for yourself with one of the many available online calculators. Our electronic health records (EHR) systems automatically display your BMI when arriving for your doctor’s appointment.
When I began my family medicine rotation in medical school, it surprised me how many people didn’t know their weight was an issue. The conversation would often start with, “Sir, do you have any concerns about your weight?”
“No, never thought about it,” the patient would reply. “Well, according to your height and weight, your BMI is 36, which puts you in the obese category,” I’d say. “I knew I had some extra pounds, but I didn’t know I was obese.”
About half of the conversations took place in this manner, and when someone hears “obese,” all sorts of bells and whistles go off in their head. Sometimes, having that initial conversation with your provider allows the ball to get rolling towards improving your health.
Being shy or afraid of the stigma surrounding obesity is common. I recommend building a trusting relationship with your physician. Trust that your physician is well trained and has the best intentions to help you overcome obesity.
Although the modern medical school curriculum is scarce on obesity topics, we have increased attention on training physicians who are communicative, empathetic, and understanding of the challenges that patients face.
Risk Factors
Genetics has been an increasing area of study for the causes of obesity. Most notably, the leptin gene has been a “hot” area of research. Leptin is a protein made by your fat cells that tells your brain about the amount of fat stored in your body. Also, leptin, along with other hormones, contributes to the feeling of satiety after eating a meal. Understandably then, a study showed that a leptin gene deficiency can lead to hereditary obesity.
However, this is a rare cause of obesity in the US.
The overwhelming cause of obesity is from insufficient usage of absorbed calories.
But what if you have a slow metabolism? I was convinced that I struggled with weight-loss because my body just wasn’t burning many calories. It was frustrating to go through cycles of exercising, weight checks, and diet modification without seeing progress. However, it wasn’t until I began strictly tracking my caloric intake and expenditure that I realized how much I was eating.
Yes, you can change your body’s metabolism. However, approximately 80% of your body’s energy expenditure occurs in cells during rest and food processing. It’s tough to tell your cells to burn more calories during rest.
Exercise promotes building muscle. As your muscles grow, they require more energy, even while at rest. Hence, exercise is the best way to boost your metabolism.
Complications
It would be wrong to discuss obesity without mentioning some of the obesity-related illnesses. While many associated diseases can be caused by obesity, there 7 essential conditions to be aware of.
Diabetes mellitus
Most people are aware of diabetes. In adulthood, diabetes occurs because your body loses sensitivity to the insulin released by your pancreas.
Diabetes is a severe illness and can lead to heart attacks, kidney failure, vision loss, and nervous system problems.
Hypertension
Our heart continuously pumps blood through a network of blood vessels throughout our body. Each blood vessel provides a source of resistance to blood flow. In obesity, the high amount of fat tissue increases the amount of total resistance, which in turn raises blood pressure.
Hypertension is a silent killer. It is the most important contributing factor to strokes. Additionally, it can lead to heart attacks, heart failure, and kidney damage.
Dyslipidemia
Dyslipidemia is a fancy word for high levels of fat in the blood. We always have fats circulating in our bodies, transferring from storage areas to our livers, where it is processed into usable molecules. Obese people have an increased amount of fat in their blood, which can lead to plaque formation in blood vessels.
Plaques in blood vessels can damage any part of the body, depending on which artery has a narrowing. This commonly presents as peripheral vascular disease, hypertension, heart attacks, and strokes.
Heart disease
Heart disease is a complicated process and is related to all three topics mentioned above. Heart disease in obese patients is commonly caused by hypertension or diabetes. As the heart loses its ability to pump sufficient blood throughout the body, patients classically develop shortness of breath, swelling of their legs, and difficulty performing any physical activity.
Stroke
Occlusion of an artery that supplies the brain is bad news. Depending on which route is blocked, patients present with varying symptoms.
Commonly, we look for changes in facial expression, muscle weakness in the upper or lower body, and problems with speech.
Sleep apnea
Sleep apnea is another silent killer. Patients who are obese have increased weight distributed over their chest and neck. As a patient sleeps, the increased weight collapses the trachea causing snoring and decreased oxygen reaching the lungs.
Over a long period of low oxygen delivery to the lungs, the heart adapts to pushing additional blood into the lungs for oxygenation.
This leads to pulmonary hypertension and heart failure.
Cancer
An increased amount of stored fat tissue causes a consistent state of inflammation. Inflammation is an essential mechanism in our bodies to fight infections, but when consistent, it can lead to cell mutation. Cellular mutation is the basis of cancer.
Additionally, fat cells produce higher levels of a hormone called estrogen. Increased estrogen is a common cause of breast, ovarian, and uterine cancers.
How to Approach the Conversation With Your Provider
Most of the time, your doctor should address your weight during an appointment. However, if you’re concerned about your weight and would like to initiate the conversation, some methods can help facilitate the discussion. There are 4 crucial considerations to contemplate before seeing the doctor.
- Start by writing down your feelings about your weight. Do you feel upset, sad, shy, angry, or perhaps you feel impartial? This is important for your physician to know to assess your motivation about creating change.
- Next, write down your ideas about what might have contributed to your weight gain. Consider your lifestyle, eating habits, activity levels, and other illnesses that you’re being treated for. Think about your family history. Did your mother have a thyroid disorder, or did your father battle diabetes? Write down how you see your self-image.
- Then, record your fears regarding obesity. Some patients have told me that they fear a stroke or heart failure. Some have said that they want to avoid diabetes. Consider why it’s vital for you to be in a healthy weight range.
- Lastly, write down your expectations for the visit. Do you want your doctor to prescribe a medicine, or are you looking for resources in your community to help you lose weight? Consider if you would like to be screened for illnesses associated with diabetes. Or perhaps, you need financial aid in obtaining healthy food to feed yourself and your family. Believe me in saying that your physician’s reach to help you is far greater than prescribing medicine or telling you to have surgery.
In my experience through medical school, we have lectures and classes dedicated to helping patients with resources. Whether you need to see a dietician, a nutritionist, a physical therapist, or a resource counselor, we are there to help you achieve your optimal healthcare needs.
These 4 steps will help your physician tailor the approach to your weight goals. It will also help them discover whether or not there is an underlying condition that may have caused weight gain. To be completely honest, this approach to the discussion is taught to doctors as a concept called motivational interviewing. Unfortunately, though, with the time constraints and stress that doctors face, this discussion method is often overlooked.
This is why you need to take the initiative and bring your feelings, ideas, fears, and expectations to the doctor.
Most importantly, be the best self-advocate for your health. If a physician doesn’t want to listen to your concerns, then move on and find someone who will. This will take dedication and motivation on your part, but many wonderful physicians will understand your difficulties and help you make the right improvements. Remember that obesity is a complex illness. You and your physician must work cooperatively.
When I see patients in the clinic who present with a list of topics regarding their health, I am impressed by their preparation and assertiveness. It tells me that the patient has done their research and is ready for my help. I lend them my ears, and the answer to their problem many times comes through the discussion of their ailment.
For instance, one of my patients struggled with weight loss, and her lab results showed that she was pre-diabetic. She began describing her lifestyle, her stresses at work, and how they lead to fast lunches, snacking at her desk, and nightly take-out for dinner. Her stress lead to daily alcohol use.
As she described her habits, it became apparent to her why she struggles with weight loss. We worked together to device a daily routine that would help her cope with stressors and manage her caloric intake. The answer presented itself through conversation.
…no disease suffered by a live man can be known, for every living person has his own peculiarities and always has his own peculiar, personal, novel, complicated disease, unknown to medicine.
Leo Tolstoy
Treatment
Since obesity is a complex illness, it requires a complex approach. In healthcare, it’s crucial to approach obesity from a multidisciplinary effort.
Treatment is divided into dietary changes, physical activity modification, behavioral, and medication therapy.
Many diets can promote weight loss. Whether you focus on low-fat/low-calorie, moderate-fat/low calorie, or low-carbohydrate, the most critical aspect is to decrease the number of total calories consumed.
Research has shown that adults who limit their caloric intake between 800 to 1200 calories per day are successful at losing weight. Dropping below 800 calories was associated with decreased weight loss.
Diet alone can create significant changes. However, these changes come with strict adherence to a particular plan. In my experience, most patients struggle with adhering to a new low-calorie diet. It’s challenging to do, especially when you’ve built a lifetime of poor eating habits.
Behavior therapy helps you adapt to the dietary and lifestyle changes needed to lose weight. Whether it’s working with a trained psychologist or joining a self-help group, the patients I’ve worked with are far more successful when you’re on your weight loss journey with others.
The decision to pursue medication therapy is individualized. If you have barriers that are insurmountable in attempting to lose weight or you’ve tried and tried, but lifestyle modifications are not helping, then medications may be a reasonable option.
If all else fails, or there is a severe obesity-associated disease, then bariatric surgery is our definitive treatment. Bariatric surgery limits the space within your stomach and decreases your appetite. Also, bariatric surgery has been shown to help treat obesity-related diabetes.
What’s in Store for Our Future
Obesity is on the rise, and without severe cultural changes, it will continue to increase in years to come.
We need to be aware of the difficulties individuals face both with their health and stigma directed against them. There need to be changes made in our approach to diet and lifestyle. Many obesity-related illnesses are preventable, and we could significantly improve our survivability by addressing the obesity epidemic.
If you’re battling obesity, open the conversation with your healthcare provider using the “feelings, ideas, fears, and expectations” approach. Understand that obesity is a chronic illness and help from others will assist you in reaching your goals.
