Doctors lack training in treating overweight patients

Thursday, July 10, 2003

The doctor walks into his examination room, where an overweight female patient waits. "Still fat," he says, shaking his head.

The woman lets out a nervous chuckle, hoping a punch line is about to follow to ease the shame intensifying inside her. But the doctor says nothing more, and she is too humiliated to bring it up again.

Within a year, the woman finds a new doctor -- a nutrition specialist who deals sensitively but directly with her obesity -- and drops more than 75 pounds.

"The doctor shook her up, but in the wrong way," said her new doctor, researcher Pamela Peeke. "He ended up losing her as a patient."

It's a scene that plays out daily in doctors' offices across the United States. Uncomfortable with their patients' weight issues, physicians either attempt to make light of the condition or ignore it altogether.

It's not intentional, say medical experts, who instead point fingers at medical schools, most of which lack curricula to teach budding physicians how to approach and handle this sensitive issue.

But with America in the midst of an obesity epidemic linked to an increase in heart disease, high blood pressure, dangerous cholesterol levels, cancer and diabetes, medical schools may finally be waking up to smell the coffee -- no sugar, no cream.

The latest statistics from the National Institutes of Health show that 61 percent of U.S. adults are overweight, with body fat at 25 percent or higher, and one-third, at 30 percent body mass or higher, are obese -- putting them at increased risk of death.

Without medical intervention, "Their next meal could be their last," said Dr. Jim Early, director of prevention at University of Kansas School of Medicine in Wichita.

Doctors themselves say they need more advice -- in the form of training in nutrition and the links between diets and obesity. A 1999 study by the U.S. Department of Health and Human Services' Maternal and Child Health Bureau reported that pediatricians, especially, are at a loss when dealing with unmotivated, hypersensitive, overweight kids and uninvolved parents.

For others, the frustration lies with adult patients who refuse to acknowledge, let alone deal with, their weight problems.

"People get very defensive about their weight," said Patricia Loofbourrow, a former family physician who now offers medical advice online on "Doc Trish Explains It All." "That makes it hard to help them."

When she was a practicing physician in San Bernardino, Calif., Loofbourrow said she felt an obligation to advise obese patients when their weight directly affected their health, even at the risk of offending them -- "Which is worse?" she reasoned. But because her medical background lacked specific nutrition training, most of her advice was general.

"Doctors can handle general questions for patients with bad back or heart problems, wanting to know if they can start a particular exercise program," she said, but once weight issues come into the examining room, doctors often lack the background in nutrition to offer specific help.

Dr. David Heber, professor of medicine and director of the Nutrition/Obesity Training Program at the University of California at Los Angeles, agreed.

"We have done a good job teaching (students) about drugs and surgery," he said, "But nutrition is still an elective."

The good news is that many hospital staffs, medical school administrators and physicians in private practice are stepping up to the plate. Some are doing it by creating programs that serve their own patients' needs, while others are opening up the field of nutrition to medical students and physicians.

Peeke, for example, is teaching and developing new medical curricula in nutrition at the University of Maryland School of Medicine in Baltimore, where she serves as an assistant clinical professor. Her class addresses everything from good eating habits and fad diets to metabolism and steak-and-potatoes versus vegetables -- anything she thinks will make her medical students more effective doctors.

In private practice, Peeke uses an unconventional approach. For starters, patients know to bring their "sneaks" for appointments "because I like to multitask -- walk and talk at the same time," she said.

In 2001, she and 12 of her female patients dubbed themselves "Peeke Performers," trained for six months, then ran in the New York City Marathon. Later this summer, Peeke and some of those same women will hike up New Hampshire's Mt. Whitney.

Dr. Michael Dangovian, medical director of cardiac rehabilitation and wellness at William Beaumont Hospital in Royal Oak, Mich., uses a totally different approach -- yoga.

"What works for me and my patients is developing more awareness on different levels," Dangovian said. He runs free yoga classes weekly for his cardiac patients, whose health problems often are linked to obesity.

Dangovian's inspiration came after reading "objective evidence" showing exercise and mindful meditation can reverse heart disease. The problem with obesity, Dangovian said, is that people eat too much, not always because they are hungry.

"We are satisfying -- or suppressing -- a lot of different needs," he said. "By working with yoga, meditation and imagery, we can look deeper to what causes that urge."

At the University of Kansas Medical School, the push is for sharing the wealth, with a public health class for senior students. The future doctors are being taught to keep data on their patients' successes and challenges to find patterns to help the community benefit as a whole, according to Early. If all diabetic patients were doing well under one doctor's care, for example, that doctor would share her methods with others.

Early said medical staffs at both the University of Kansas and Kansas State University recently combined efforts to develop weight management programs for families, taking into consideration cultural differences that impact eating and exercise habits.

America on the Move is the newest program from Dr. James Hill, director of the Center for Human Nutrition at the University of Colorado and regional vice president of the International Association for the Study of Obesity. Patterned after an earlier successful effort, Colorado on the Move, its goal is to help people get active without drastically altering their lifestyles.

"It's based on making small changes in physical activity -- walking 2,000 extra steps each day, and eating 100 calories less each day," Hill said. "It is a fun, simple program that we think can be a grass-roots movement to begin addressing obesity."

GROWING NUMBERS

  • 1990:The year Congress mandated improved nutrition education in all U.S. medical schools

    33: Number of accredited U.S. medical schools with required nutrition courses, 1997-1998

    Less than 6: Percentage of all medical school graduates who received adequate nutrition training in 1998

    SOURCES: The Association of Medical Colleges, the University of North Carolina at Chapel Hill, The Intersociety Professional Nutritional Education Consortium

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