When doctors diagnose health problems in patients, they tend to offer solutions: antibiotics for an infection, surgery to remove a tumor, insulin for diabetes.
But for the most part that doesn’t happen when the diagnosis is obesity.
While doctors are getting better at informing their patients when their body mass index is too high, they often do not tell them how to lose weight, even though a range of options – including medication, gym memberships, a nutrition program like Weight Watchers, or referral to a weight-loss specialist or surgeon – are available.
Many doctors report they don’t have time to talk to patients about weight loss strategies, while others struggle with being overweight themselves and feel uncomfortable broaching the subject with a patient. Many doctors simply haven’t been trained.
“A lot of us don’t exactly know what to tell patients,” admits Dr. Jennifer Caudle, an osteopathic family physician and assistant professor at Rowan University School of Osteopathic Medicine in New Jersey. “You don’t get a lot of nutrition training in medical school.”
But doctors can still influence their patients to lose weight. A study published last year by the University of Georgia found that patients were more motivated to lose weight after their doctors advised them to do so, even if they weren’t prepared to hear the message. Another study showed that patients were more likely to understand their weight and try to lose weight after talking to a doctor.
Obesity can contribute to a host of medical problems, including heart disease, sleep apnea, stroke and cancer. With two-thirds of the U.S. population overweight or obese, the Obama administration has made tackling the issue a national priority through revamping meals in schools and encouraging people to exercise more.
Despite this push, the message is still not being delivered effectively at the doctor’s office.According to the Centers for Disease Control and Prevention, during obesity-related medical visits, doctors discuss diet and nutrition only a third of the time. In 24 percent of visits they discuss exercise; weight-reduction education, including referrals to other health professionals, occurred in 26 percent of visits.
These sets of advice overlapped, meaning that in 60 percent of doctor visits specifically for obesity, patients received no advice at all.
“The silver lining here is that until very recently doctors did not bring up weight at all with patients,” says Dr. Scott Kahan, a spokesperson for the Obesity Society and director of the National Center for Weight and Wellness. “We’ve seen a nice and important shift in the last 10 years … but the problem is doctors generally are not offering very productive health applications.”
The U.S. Preventive Services Task Force, a government-appointed medical panel,recommends screening all adults for obesity. The panel’s endorsement means that under the Affordable Care Act, President Barack Obama’s health care law, health insurancecompanies must reimburse doctors for notifying patients that they are overweight or obese, without cost to the patient.
Beyond that, insurance plans vary regarding what measures are covered. Citing concerns about effectiveness and lack of long-term data, the task force did not recommend that insurance companies cover weight-loss medication, and many plans do not coverbariatric surgery.
Members of the task force cited multiple approaches to obesity as showing some effectiveness, including setting weight loss goals, attending group sessions, improving diet and working with patients to address how to maintain lifestyle changes. They pointed out, however, that some primary care doctors may find all of these items impractical, and that referring patients to community-based programs would help.
Doctors can find it challenging to take on so much. “One of the biggest issues is that there’s so much need by patients and there is so little that doctors have to offer right now because of lack of training and time,” Kahan says. “It’s like this head-butting that occurs. Everyone walks away being unsatisfied.”
Dr. Justin Reno, a family physician at a rural clinic in west Tennessee, says that “without a doubt” doctors are being asked to do a lot. “And that’s not a bad thing,” he adds.
The odds of influencing patients are difficult, he says. Reno knows his patients are bombarded with marketing of foods and drinks that are bad for them. “Getting people away from those influences requires more than simply 15 minutes with a physician every month,” he says. He likened the experience to that of learning a musical instrument. “The vast majority of hard work and effort happens between the information that you’re getting from a music instructor,” he says.
Michael Hook, from Chambersburg, Pennsylvania, who was overweight until recently, understands the difficulty of being told to lose weight without receiving any specific advice for how to do so. In appointment summary forms from his doctors, he had been listed as “morbidly obese,” and four doctors gave him the same advice: “Get the weight under control.”
The advice never went beyond that, and it wasn’t until a few years ago that he started thinking seriously about his weight, after hearing about a friend who was dealing with a perforated colon.
Now 62, Hook went from 293 pounds to 160 pounds by making lifestyle changes. “Several doctors told me of the possible benefits of losing weight, but stopped short of ever pointing me in the right direction,” he says, then adds: “I’ll admit that I could have been more proactive by asking and insisting.”
Reno admits the experience can be frustrating, both for the patient and the doctor. “As time goes by and there are no changes, you lose of the energy because you feel like you have other medical conditions to discuss,” he says.
Addressing weight is difficult, Reno says, but is necessary. “It’s just like cigarette smoking,” he says. “The issues that are toughest have to be talked about the most.”
Barry York, 44, from Columbus, Ohio, has been trying to treat his obesity for years. His weight fluctuated, and during the times when it was lower he says he would starve himself or do juice diets. Though he exercises a lot – running half marathons, biking and weight training – his weight now will not go under 208 pounds.
“Clearly, I needed some guidance from someone about nutrition, sleep and stress,” he says. Every six months, his doctor tells him he needs to lose weight. When Barry asks what to do differently, she tells him to burn more calories than he eats, or suggests becoming a vegetarian.
He says his job as a software engineer is stressful, and that his weight affects his sleep. “What I’ve come to understand is that doctors don’t understand nutrition as well as other topics,” he says. “They don’t offer up much in the way of a solution. I need to know what’s missing and what might work for someone like me.”
Physicians and nurse practitioners report they have less respect for patients whose body mass index is higher – a stigma that can adversely affect treatment. And Dr. Holly Lofton, assistant professor of medicine and director of the Weight Management Program at NYU Langone Medical Center, points out that patients notice this weight bias and often blame themselves if they can’t lose weight.
“We need to really work on the medical community accepting obesity as a disease and not as a character flaw,” she says.
For instance, Kahan knows a patient whose diagnosis of scoliosis was missed because doctors were overly focused on her weight. “Obesity hides in plain sight,” Kahan says. “It’s just as worrisome healthwise as any disorders doctors deal with, but it’s even worse because patients have to wear it on their sleeves for everyone to see and everyone to judge – even doctors.”