Point of View

For obesity, a dose of doctoring

May 29, 2012 

Henry had a problem: The medicine that calmed his mind was hurting his body. A middle-aged man with bipolar disorder, Henry had tried several medications before he became my patient. The only one that stabilized his mood made him crave fattening foods so intensely that after three years on the drug, he’d gained 50 pounds.

With this excess weight came diabetes, hypertension and high cholesterol – and with them, more drugs to take. At each visit, I urged Henry to keep his weight under control, but he kept gaining. Frustrated, I decided to let his primary care physician decide how to help him. After all, his mental health was in good shape. Ultimately, his weight wasn’t really my concern.

Today, however, no doctor can afford to think that way. Between 1980 and 2000, the percentage of obese Americans more than doubled; in children and adolescents, it tripled. A current study in the American Journal of Preventive Medicine reported that while the rate of increase has slowed since 2000, the numbers are still rising. If they continue at this pace, 42 percent of American adults will be obese by 2030, costing our country an estimated $25 billion annually. Obesity is everyone’s problem.

Even though we see the obesity epidemic up close and wage our own battles with the scale, doctors often don’t know quite what to do with obese patients. Just like our patients, we become impatient, frustrated and, at times, disgusted. Surgeons curse higher complication rates and sometimes refuse to operate, while medical specialists bemoan rising rates of weight-related chronic conditions. Obstetricians see more cases of gestational diabetes while pediatricians treat children with problems previously seen only in adults.

In psychiatry, many of us have accepted obesity as collateral damage, since some of our best medications can cause substantial weight gain. Often removed from day-to-day general medicine, we’re tempted to punt responsibility back to the primary care physician as I did. Even those of us deeply concerned with our patient’s expanding waistlines must acknowledge that compared with the psychotic delusions of schizophrenia or bipolar mania, it’s better to be fat. Establishing mental stability while maintaining a healthy weight often seems incompatible.

Or at least that’s what I thought until Henry showed me otherwise. Just when I’d decided to stop nagging him about his weight, he showed up one day 10 pounds lighter. At first, I worried that he might have cancer or some other medical problem. Instead, I heard in amazement his simple explanation:

“I finally started listening to you. I’m changing my eating pattern and walking each day.”

By the next visit, he’d lost five more pounds, and three months later, another five. Three years down the road, he’d dropped 55 pounds, all while taking his bipolar medication. He no longer needed diabetes or blood pressure pills.

Then, six months ago, after missing an appointment, Henry had a setback. My heart sank as the scale showed he’d gained almost 10 pounds. Since every study shows that keeping weight off is harder than losing it, I feared this was the beginning of an inevitable backslide.

I reminded Henry of how far he’d come, encouraging him while silently doubting he’d get back on track. When he returned to my office three months later, however, not only had he shed the weight that he’d recently gained, but he’d lost a few extra pounds, too.

“Seeing you helps keep me on top of things,” he said. “I never thought my psychiatrist would be the one to help me get my physical health right.”

Henry had reminded me how important simple doctor-patient interaction can be. While the tide of obesity exceeds the power of any individual physician to defeat, all of us who serve on the medical front lines need to engage in this fierce battle. Sadly, that is not happening. According to a 2011 study, nearly one-third of obese patients had never been told by a doctor that they were overweight. Some doctors think it’s a waste of their time. Others complain their efforts won’t pay enough.

But these excuses are unacceptable. Just like our obese patients, we have a responsibility never to quit. Talking and persistence are sometimes the most powerful medicines for both doctor and patient. And as we’re all aware, it’s not just Henry who has this problem.

Damon Tweedy, M.D., is an assistant professor of psychiatry at Duke University Medical Center and staff psychiatrist at the Durham VA Medical Center.

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