Why Doctors Have a Difficult Time Treating Obesity

Howard Markel, MD, PhD


March 01, 2005

In many ways, Jake is a typical 16-year-old American boy. He enjoys playing video games, listening to rap music, and watching action-packed movies with his friends. And, like almost 20% of all American youth, Jake is overweight. In fact, at more than 300 pounds, there's no subtle way to describe Jake's physique. Doctors like me might use an obtuse clinical term such as "morbidly obese." His teenage buddies, far less polite, typically deride him by calling him "The Fat Man."

A few months ago, a social worker colleague asked me to see Jake. She had excellent reasons to be concerned. Not only was he physically huge, his health was dangerously compromised. At 195/100 mm Hg, Jake's blood pressure was alarmingly high; his cholesterol soared above the 300 mark; and his blood sugar levels placed him in a concerning category called "prediabetes."

Few today need to be reminded of the epidemic of expanding waistlines. Most alarming is the spread of this health problem to youngsters. Because eating habits are established early in life and most overweight children tend to remain that way when they become adults, many public health experts are predicting a huge increase in the incidence of obesity-related conditions. These will include atherosclerosis, heart attacks, hypertension and strokes, adult-onset diabetes mellitus, and even osteoarthritis, occurring as a result of carrying around all those extra pounds for so many years.

But even more disturbing than the plethora of fast food, soft drinks, and snacks that have invaded our children's schools and daily lives has been the relative inactivity of physicians in arresting this problem. The complaint of how little we doctors learn about nutrition, exercise, and healthy diets is, sadly, a valid one. The medical school where I teach offers only a few hours in the formal curriculum on these subjects, whereas there are weeks devoted to explaining the drugs we have available to treat hypertension and adult-onset diabetes. Even more time is allotted to the burgeoning number of after-the-fact surgical interventions for problems that could be prevented, or at least attenuated, simply by eating right and engaging regularly in physical activities.

At the clinic where I see Jake, we really don't offer any of the dietary counseling or nutrition classes that might help him. It's also very difficult finding the time to address the importance of cutting calories and eating healthy at the family level where obesity typically originates. I could, however, get him an appointment to see a surgeon to consider performing an expensive, and not entirely safe, stomach-stapling procedure simply by making a 2-minute phone call. This is hardly unique to my practice.

Perhaps the root of this problem lies in the fact that doctors, as a rule, like to succeed in their treatments. We gain great satisfaction from surgical procedures that quickly remove an offensive tumor, or prescribing pills that quickly arrest a medical condition. But most of us find treating obesity frustrating, if not outright hopeless. This problem is only exacerbated by the sad fact that most insurance companies rarely reimburse clinicians who are willing to spend the long hours it takes encouraging these kids to learn an entirely new approach to eating. As a result, many avoid treating patients with obesity entirely.

Jake and I decided that we would meet weekly for a weigh-in and a chat about his progress. At the close of our first visit, we consulted the Internet for a sensible and safe diet suggested by the American Heart Association. He also agreed to begin a program of regular exercise by walking at least a mile a day with the intention of increasing that amount over time. And I promised to supplement my own pitiful knowledge on the art of losing weight by studying some of the latest findings and textbooks on the subject. Most important, we made a pact to learn how to fight this remarkably stubborn health problem together.

About 2 months later, Jake's track record has been good, albeit not spectacular. He has managed to lose 11 pounds. He is sticking to the diet and exercise regimen I prescribed and remains determined to lose weight. As Jake admitted the other day, "this is really going to take a long time, isn't it?"

His social worker and I are committed to his weight loss goal as well. We only hope Jake's health insurance plan continues to support what I have come to label "nutritional cheerleading visits." These sessions, to be sure, are less exciting or definitive than open-heart surgery, but they just may save his life.


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