COMMENTARY

A More Effective Approach to Childhood Obesity

Sébastien Vermeulen, MD

February 09, 2022

BRUSSELS — A 13-year-old boy comes to my office. The scale says he's over 120 kg, and blood tests indicate the onset of diabetes. The boy is the nephew of one of our secretaries. When she told him that she knew a doctor who'd lost a lot of weight over the past year, he couldn't believe his ears.

He's barely entered the room when he looks at me and asks: "So, when can I start?"

On the spot like that, I'm not quite sure how to respond. It's not like I have a bag of tricks handy that I can reach into. I tell him that I'm going to have him see a specialist who will be better able to help him with the not-so-simple task of dieting.

"Ok," he replies. "So, in the meantime, I'll treat myself for as long as I can!"

Sigh.

Childhood obesity has become a full-blown crisis. There's not much about the current situation that gives hope for the future. The pressure it is putting on the healthcare system is only going to get worse. Personally, I think childhood obesity is a distinct condition that isn't suited to being treated single-handedly by a general practitioner. That's not to say that primary care physicians don't have an important role to play; we're in a position to see the first signs and turn things around before they get out of control. Still, we shouldn't hesitate to make that referral to a specialist.

Often, the patient's family members also have weight problems, which makes treatment more complex. It's not unusual to find that it's not just the one child who has obesity; brothers, sisters, even the parents do as well. Although genetics might very well be one of the causes, lifestyle, too, is a significant factor. But it really doesn't make sense to put the child on a diet if the rest of the household isn't going to play their part. As harsh as it sounds, if we can't get the whole family to sign on, we might as well just go ahead and scrap the plan.

When it comes to managing obesity in adults, though, the family doctor can indeed play a key role. There's clearly still a preventive component, but these patients have such a significant medical diagnosis that, I think, prevention must be looked at as being a separate piece of the puzzle.

My Own Weight Loss Story

At the beginning of this essay, I mentioned a doctor who had lost a lot of weight. Well, that doctor is me. My weight was clearly trending upward and had already landed me in the "pre-obesity" category. There was a good chance that it would end up fluctuating over the next 10 to 20 years. Making changes was not easy, but I feel so much better now, both mentally and physically. And I'm no longer afraid to look my patients in the eye when they ask me for weight-loss advice.

That fear I used to experience is consistent with research that shows that doctors who themselves are obese are more likely to have difficulty broaching the subject with their patients. And their patients are less likely to take their advice seriously, although it must be noted that there's also research that shows precisely the opposite.

I also realized that I had only the most rudimentary knowledge about the subject. In med school, we're taught very little about prevention. The training primarily focuses on how to treat symptoms and how to come up with treatment plans that are in line with various guidelines and recommendations.

Several studies confirm that although there's great potential for managing obesity in a primary care setting, doctors often lack the know-how required to effectively address the condition and advise the patient. As a result, doctors are sometimes unsure of themselves and have difficulty starting the conversation, let alone rolling up their sleeves to get an accurate picture of the case and actually tackling the problem.

I'm still very unsure of myself when it comes to talking about nutrition and weight loss, two areas that I am always exploring yet still feel far from having a grasp of. Refresher courses, additional training programs, and a structured framework for consultations could help clear away our doubts and get us to the point where we're providing more effective management in a primary care setting.

Addressing the Stigma of Obesity

Another issue is that because of the many prejudices regarding obesity, it's not that easy for people to summon the courage to get help. It's not unusual for patients with obesity to be viewed as lazy, having no willpower, or lacking self-control. To properly address patients, healthcare providers must put these kinds of ideas aside and tackle what is really a much more complex problem.

The fear of stigma is one of the reasons some patients wait so long before making an appointment with a professional. In fact, studies have shown that after a person realizes that they have a weight problem, it can sometimes take 6 years(!) for them to actually discuss it with a doctor. The way I see it, those 6 years are 6 years of missed opportunities. We've got to shorten that timeline. Going forward, we general practitioners are the ones who are going to have to initiate the conversation.

It's not that simple, however, because it's a very sensitive subject for some people. The patients themselves sometimes stop the conversation before it's even started.

Another challenge we're currently facing is the movement to normalize excess weight and obesity.

Another challenge we're currently facing is the movement to normalize excess weight and obesity. In my opinion, this is a rather troubling development. (Holding this view will certainly not win me any popularity contests.)

Social conditioning clearly comes into play. As we go about our daily routines, we encounter a fair number of overweight people. The more we do, the less we notice it and — eventually — we end up coming to view obesity as just a regular part of life. Because of this, it will become more and more difficult to identify individuals with obesity who are at the point of being at risk, and individuals with a low but normal BMI might be mistakenly considered too thin.

These days, we're presented with a multitude of opinions. There are even TV shows that focus on the lives of people who are overweight. For example, the Belgian television show Albatros shows how trendy the theme of weight has become of late. And not long ago, Belgium's former Minister of Public Health, Maggie De Block — who is herself a doctor — said that she wanted to be a "role model" for obese individuals. I understand the message that she was trying to get across, that stigmatizing people because of their weight is reprehensible and absolutely unacceptable. That said, I do not agree that things should simply be accepted as they are.

We need to make more of an effort to raise awareness about obesity and make sure that people know about the related health consequences. The impact that obesity has on quality of life is too great for us to just stay silent, especially because people do not automatically see the connection between their aches and pains and their weight.

I have realized that, in my daily practice, I have shown very little concern about this. I have not routinely taken note of my patients' weight, not to mention their waist size. And the literature confirms that I'm not the only one.

In primary care, changes in weight and height are not really monitored. When they are, it's often because a serious health condition already exists. From the first visit, we should make it a habit to record the patient's weight, height, and waist size. This way, we'll be able to compile information that could prove extremely useful in identifying the first signs of obesity. Thorough records can supplement other information in the patient's file, allowing us to get a clear picture of the course of these parameters over the months and years.

Let's be clear. No one can force anyone to lose weight. Everyone is free to live their life as they wish, and everyone has the right to get the best care possible, regardless of their life choices. But we can't lose sight of the fact that with an ageing population and an obesity pandemic that doesn't seem anywhere near coming to an end, Belgium will have a healthcare system that will be under tremendous pressure in terms of capacity and costs for decades to come. Who is going to pay for it?

An effective strategy incorporating a serious investment in the management of obesity can bring about substantial savings in the social security system. Those savings can then be reinvested in other (health) sectors.

Sébastien Vermeulen was born and raised in Halle-Zoersel, Belgium. He has a wide range of interests spanning many fields, and a particular passion for psychiatry, palliative care, diabetes, obesity, and ENT conditions. He works as a general practitioner both in private practice and at the Center for Forensic Psychiatry in Antwerp.

This article originally appeared in Mediquality from Medscape.

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