Graceful Healing with Dr. Brandy Robinson - Talking About Obesity
A few of you may be wondering why I decided to start a blog. Well, I’m no computer genius, but I can type like the wind. And thank goodness I have my daughter who knows about all things technical! But essentially, as a family practice physician for the last 11 years, I have been blessed to be a part of my patient’s lives. When my patients are happy about some progress they have made, I feel joy along with them. When they are dealing with setbacks and losses, I cry with them and pray for them too. I realized that these wonderful experiences have given me a chance to help others - and so now I have a blog.
One of the first topics I would like to tackle is OBESITY. This seems to be one of the most frequent patient complaints that I deal with daily. So why does weight really matter? Obesity can lead to serious comorbidities like Diabetes, High Blood Pressure, which in turn can increase mortality rates as well as the risks for heart attacks and strokes. We as a society are obsessed with our weight, our physical image, and how we appear socially. This obsession can lead to depression, anxiety, and suicidal thoughts.
So how do I deal with obesity in real life?
First, I do the one of the hardest things for a doctor to do – I tell the patient, “You need to lose weight.” But that’s not a hard thing to do! Right? Wrong. When patients come in, they want to please their doctors. They want to hear – “Good Job!” or “Your Blood Pressure Looks Great!” And we, as doctors don’t want our patients to feel bad about themselves. We want them to be happy when they come in. But just like a parent can’t let his/her child eat Cheetos all day because they want to keep their children happy, similarly, a doctor can’t let a patient go out the door without at least a quick conversation regarding weight. I get it. You just spent 30 minutes going over all the patient’s complaints and there’s no time to mention weight. However, I say it can be as easy as saying – “I noticed your weight has gone up compared to this same time last year. What are your thoughts on that? Did you know I offer medically supervised weight loss for my patients? If you are interested, please schedule a follow up visit.”
Doctors, trust me – your patient WANTS to talk about weight and how they can lose it!
Patients, trust me – your doctor WANTS to talk about weight and how you can lose it!
One of the hardest things for a patient to do is talk about weight loss. But patients want to tell their doctors all their health problems! Right? Wrong. Getting on the scale at the doctor’s office is embarrassing. Talking about losing weight may bring up some unpleasant memories and feelings that a patient doesn’t always feel like sharing. Instead of shame, some patients may feel hopeless. They think, “I’ve done diets before and they didn’t work,” or “I’ll never be able to keep the weight off.” Well this is a very common thought that most, if not all, obese patients have had. My advice to these patients is to fight for your health. When you go the doctor’s office you should mention everything pertinent to your health and that INCLUDES the taboo topic of obesity. Don’t expect that your doctor can give you a comprehensive weight loss plan in a matter of seconds. Just like you need time to try on clothes and get the best fit, your doctor needs to have that same amount of dedication regarding weight loss. That usually requires a separate appointment so we can go over options and come up with a treatment plan that is good for your body and for your health.
After I have a conversation about weight loss with a patient, I follow up by assessing health needs and creating a custom treatment plan. It goes a little like this:
1. What are the patient’s expectations?
2. What are the patient’s triggers?
3. Run the Numbers
4. Consider Medication and Surgical Options
Now, let’s take these considerations one by one and break down the process.
This is the most crucial step in order to achieve any lasting weight loss. For the patients, expectations may be a specific number of pounds they want to lose, or fitting into a certain style of clothing, or treating for and preventing secondary diseases related to obesity. Finding the motivations and speaking towards goals will help the patient stay the course for the long road. It will also give patients guidance regarding which goals are achievable and reasonable. No, it’s not healthy to lose 20 pounds in 1 month! Circling back to expectations at every visit is a good way to keep the patient engaged in their progress and weight loss.
I start with peppering patients with important questions like – How long have you been overweight? How did you gain weight? Was it due to an illness, injury, pregnancy? Have you been dealing with obesity long term? Do you feel the weight gain is due to overeating, genetics, or lack of exercise? Once I understand the triggers, I can offer treatment options to give maximal weight loss. Patients who have been overweight long term usually don’t have a specific trigger. These patients are sometimes plagued with a family history of obesity and even genetic ties to it. Those who have been overweight long term will require a different treatment than those who have only recently gained weight (less than 3 years). Other triggers include pregnancy/post-partum, chronic illnesses like diabetes, thyroid disease, medical issues that involve heavy use of steroids, mental issues, mood disorders, and injuries that limit range of motion and mobility.
Run the Numbers
Now that I’ve got some background on the how and why, I then start by educating patients on their numbers. While it’s not Algebra, the numbers of nutrition are very important. The first numbers we need are HEIGHT and WEIGHT which are necessary to calculate the BMI or Body Mass Index. Basically, the BMI is used to classify the degree of obesity and helps determine if a patient is simply overweight or if morbid obesity is present. I use these numbers to see how aggressive I need to be with treatment.
The next set of numbers is used to calculate the BMR or Basic Metabolic Rate. The BMR is your LAZY BEAR thermometer since it represents the number of calories your body needs to lay on the couch and do nothing all day. I use the BMR to help me figure out how many calories you can consume in a day and still lose weight.
Ideal weight is a calculation that gives me an idea of what is a healthy weight for my patient and an end goal. Percentage of body fat is an important number too since as a patient starts to exercise and lose weight, their muscle mass will increase while the fat decreases. These changes cannot be seen on a scale and thus need to be measured. And speaking of measuring, every visit I also measure in inches the circumference of the chest wall, waist at the umbilicus (belly button), and the widest part of the hips. The circumference of the wrist and forearm can be measured if you do not have a machine that calculates percentage of Body Fat.
I like using www.bmi-calculator.com because all of these equations are listed in the calculator and all I have to do is enter in numbers and the calculator does all the math. At the end of this massive math session, the patient and I come up with goals for BMI, Weight, and Percentage of Body Fat. These numbers should be checked at every visit.
Consider Medication and Surgical Options:
Options for the treatment of obesity are numerous and may range from dietary interventions and exercise or may lead to medications or surgery. Before agreeing on an option, I always want a set of obesity labs to see if there is a secondary cause for obesity. Some secondary causes include thyroid disease, diabetes, pre-diabetes, metabolic syndrome, polycystic ovarian disease. If there are secondary causes present, it will be very difficult for a patient to lose weight and keep the weight off. We will have to deal with the secondary causes first and then work on other options for weight loss once those secondary problems are resolved.
If one of my patients is a good candidate for a weight loss medicine, we discuss the benefits, risks, and side effects of that medicine before starting it.
Patients who qualify for surgical options usually include those who have been obese for more than 3 years, those whose BMI is greater than 35 and/or has a comorbid condition, and those patients who have had a previous bariatric surgery and are requiring a revision to promote a new round of weight loss.
And finally, medical nutrition therapy that includes a nutrition consult with a dietician can be a helpful non-invasive way to promote weight loss.
After doing the appropriate work up, treatment is started, and patients are asked to come back for recheck in 4-6 weeks. Before leaving, my patients are given specific goals to achieve by the next appointment – goals may be losing 4 pounds before the next visit, or exercising 3x/week, or increasing water consumed in a day, or keeping a food diary, etc.
In my next article on obesity, I want to discuss treatment options, medications, and surgical evaluations for obesity.
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