Perspectives on Obesity Between the Clinician and Patient Pt.2

In part 1 we went over some data that showed some clinicians may have negative attitudes about their obese patients – which sadly reflect the same negative attitudes society has on the obese (lacking willpower and etc). We explored clinician beliefs on the causes of obesity and provided contradicting data that did not support some of the beliefs clinicians had on why people gain weight. In the end, while some clinicians may have negative attitudes towards the obese, it is not clear if these negative attitudes are due to some intrinsic prejudice or were formed due to frustration in not being able to treat obesity efficiently. In this post we will go over one of the dogmas in healthcare that contributes to this frustration: “calories in & calories out”

You may already be familiar with the arguments against this concept and there are certainly other experts out there who are actively challenging this belief. Instead of going through an in depth review of the literature, I’ll provide a perspective on how this belief has influenced my formal education as a nurse, how it can effect the clinicians perspective when interacting with an obese patient and some responses I’ve received from people who felt they were treated differently by their providers due to their weight.

The basic concept of “calories in and calories out” is that eating more calories than you burn will lead to caloric excess and when you build up 3500 calories you’ll gain a pound of fat. Pretty straight forward and this concept was pounded into my brain while studying for my licensure:

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Review Material for the RN licensure that Pretty Much Sums up What you Learn in Nursing School

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Two things should jump out at you. The first is that nutrition only comprises a small portion of an RN’s formal education. The second point is that the education you need to pass the NCLEX in regards to nutrition is very thin. Additionally, most of the education on nutrition is focused on specific physiologic/pathophysiologic states and not necessarily on health promotion/prevention. The parts that are focused on health promotion are based on the usual “calories in & calories out” model in conjunction with advice such as limiting dietary fat (especially saturated dietary fats).

A lack of nutrition education extends to medical schools as well [1]

Researchers from the University of North Carolina at Chapel Hill asked nutrition educators from more than 100 medical schools to describe the nutrition instruction offered to their students. While the researchers learned that almost all schools require exposure to nutrition, only about a quarter offered the recommended 25 hours of instruction, a decrease from six years earlier, when almost 40 percent of schools met the minimum recommendations. In addition, four schools offered nutrition optionally, and one school offered nothing at all.

For those schools who do offer the minimum hours in nutrition It is likely that the calories in and calories out model is used for weight maintenance. The simplicity of this model is a big contributor to what causes so much frustration for not only the patient, but the clinician as well.

When I was still deciding on pursuing a career as a family nurse practitioner, one of the books I read was Unforgettable Faces a memoir of an FNP from her point of view while treating patients with a variety of diseases. It gives a nice personal view of what goes on in a clinicians head when interacting with patients who are suffering a host of physical, mental and socioeconomic issues. There is a section where the author talks about treating obesity that is worth a visit.

In the book, the author meets a male patient who if 5’1″ and 330 lbs. He is clearly described as obese and the author comments that obesity is one of the hardest medical problems to deal with. Flipping over his chart, the clinician notices the patient has been skipping out on appointments:

He was supposed to lose ten pounds on a new diet. Instead, he gained fourteen more pounds! Most people who seriously diet will lose weight in seven days from water loss alone. He stepped down off the scale like a boy who’s gotten a bad report card and trailed me into my room.

The patient came in originally to apply for disability related to his hypertension (which was under control with meds according to the author) and difficulty with physical labor which puts him out of breath. However, the clinician informs the patient that his shortness of breath was related to his weight and that he needed to lose weight not apply for disability.

As i looked at the morbidly obese, thirty-five-year-old man, galvanized by a strong sense of denial, I realized that the real problem was motivation. Without superior motivation on the part of everyone concerned, nothing could be accomplished. It was clear to me that this patient was malingering.

“Do you think you’d feel better if you could lose some weight?”

“Maybe,” Mr. White said indifferently with a shrug of his shoulders.

In that exchange from the clinician’s perspective, it seemed that the clinician felt the patient was unmotivated in addressing his weight. That may be true…but this tells us absolutely nothing about WHY the patient is unmotivated. The next part of the story involves the harm of using “calories in & calories out.”

“Are you sticking to your diet?”

“I try to.”

I worked out the incriminating math…The result was impressive, but did not surprise me. Leaving aside his weight gain, he was ingesting at least three-thousand-nine hundred sixty calories a day. Some diet!

His [BMI] was almost twice that level, drug treatment is necessary, but it would not be successful without dieting. If Mr. White didn’t take the matter seriously, he might be facing surgery.

“I don’t think you’re sticking to your diet. I calculate that you are eating two or three times more than you should be eating.”

He sat with his arms folded and looked straight ahead, avoiding my eyes. His face turned expressionless.

This is where “calories in & calories out” is extremely unfair to both parties. The clinician in this case calculated the patient’s theoretical daily calories based off his weight and used it as an assumption of how the patient is eating. Based on this assumption, the clinician then makes another assumption that the patient doesn’t view the matter seriously. This is all possible of course if the story is all about the quantity of “calories in & calories out,” but this simplistic view ignores the quality of where these calories come from.

This perspective is already changing a bit with people such as Dr. Lustig informing the public about how the differences in calories from sugar impact the body. Last year, another study showed how the composition of a diet can create different responses despite being isocaloric [2]

…because metabolic pathways vary in energetic efficiency, dietary composition could affect energy expenditure directly by virtue of macronutrient differences or indirectly through hormonal responses to diet that regulate metabolic pathways.

Acutely, reducing dietary glycemic load diet may elicit hormonal changes that improve the availability of metabolic fuels in the late postprandial period, and thereby decrease hunger and voluntary food intake.

In otherwords, while calories in & out tells us how much we need to eat and how much we need to expend, it tells us absolutely nothing about how the foods that make up these calories effect our metabolism and psychologic satiety. So what the study did was take overweight individuals and semi-starved them to achieve an average weight loss of 13.6% from their baseline. As clinicians, when we inform a patient to cut the calories and lose weight, there are a lot of patients who are initially successful but then eventually gain the weight back (sometimes gaining more weight than initially lost!).

What seems to happen is that metabolism decreases in these individuals to adjust for the weight lost. So this study wanted to see is if this metabolic compensation occurs with the same amount of calories but with different compositions of dietary fat, protein and carbohydrate after the initial 13.6% weight loss. To test this, the study evaluated a low carb high fat diet, a low GI diet and a low fat diet. Or another way to put it: a restricted carbohydrate diet, modified carbohydrate diet, and high carbohydrate diet. So what did they find?

This study was covered in large depth by the media when it was released a year ago so you can read over it yourself if you want a little more information. I would also recommend reading the actual study as well since there are some limitations to the study (it is written in an easy to understand manner) if you have time. But the basic finding was “calories out” differed between diets despite “calories in” being the same between all 3. The calories out were so dramatic between two of the diets (the low fat vs low carb high fat) that the author’s note:

…differed by approximately 300 kcal/d between these 2 diets [in favor of the low carb] , an effect corresponding with the amount of energy typically expended in 1 hour of moderate-intensity physical activity.

Not only was the calories out different between the three diets, but other metabolic markers differed significantly between all three despite “calories in” being the same. Again, the calories in & calories out model tells us nothing about what certain foods are doing to us metabolically and psychologically. Let’s get back to our story.

When we last left our story, our clinician had just informed the patient he must have been overeating based off calculating their weight maintenance from the calories in and calories out model. As we went over briefly, a positive caloric balance is influenced by more than how much a person simply eats. The quality of where those calories are coming from can influence a person’s metabolism. Was it really okay for the clinician in this case to accuse the patient of over eating? The clinician then continues:

“If you eat right – plenty of whole grains, fruits, and vegetables – you can still eat pretty well and it won’t seem like a diet. Do you want to talk to the dietician again?”

He thought for a moment. That face again.  “No.”

“Okay, then let’s start over and set a weight management goal. If you could lose five pounds in a month, that would be something we can work with. If you could lose anymore weight, you’d feel good that you are doing something about this.”

So there are two things to keep in mind about this conversation. How does the clinician know the patient isn’t already eating “plenty of whole grains, fruits, and vegetables?” In the previous study it was shown that restricting carbohydrate (low carb) or modifying carbohydrate (low GI diet) both yielded better metabolism and metabolic markers than a low fat high carbohydrate diet. The second and most important thing to notice is that not once did the clinician ask the patient what he was doing at home. Instead the clinician starts informing the patient that he needs to lose weight. This tells the patient absolutely nothing.

A patient who is obese has already been told that they need to lose weight from previous providers. And if they haven’t, have probably been told by friends/family and society to lose weight (sometimes unfairly). Why didn’t the clinician simply ask what sort of foods the patient was eating or if the patient thought the diet was working? And if the diet wasn’t working…how come? How did the diet that was previously recommended make him feel? Did the clinician simply conclude further exploration wasn’t necessary because the patient was obviously non compliant due to her previous calculations of calories in and calories out? The frustration from the clinician’s side starts to become more apparent:

My inner voice was less optimistic. I wondered why I bothered going through the motions. We both knew that nothing was going to happen.

Like a mother trying to coax a recalcitrant child, I felt foolish.

Without warning, Daniel White stood up. The chair creaked and groaned as if in pain as he did so…His parting words were to the point: “Dieting sucks.”

At this point the frustration from both parties was pretty clear. I think the patient’s last words are very telling of what went wrong in this meeting. Dieting for this patient does suck…but why? Were they constantly hungry all the time? Was dieting simply not working? What exactly did “dieting” for this patient mean? It just seemed the patient was informed to lose weight by the clinician. Was it not worth exploring these issues further? It could just be the patient is non-compliant, but without asking these questions we’ll never know. Ultimately, this is the greatest harm of the calories in & out model – it can lead providers to conclude that weight gain is nothing more than a patient being non compliant/weak-willed/undisciplined.

After reading this post please do not view the clinician from this book as incompetent or mean. In fact, from reading the book, she is actually a very good provider and cares very much for her patients. Her case study was used to simply highlight and explore a bigger issue – a systemic issue on why some healthcare providers may feel frustration towards obese patients. The book was also written in 1999 when a lot of the research on obesity was still new and calories in and out was still king (for many providers it still is).

However, the frustration that some patients have with the interactions from their providers for obesity related issues is still very much prevalent. After sharing part 1 of my exploration into provider attitudes with some of the communities I’m a part of, I received a touching amount of stories from people who felt their providers treated them with negative attitudes based off their weight. If you’re a provider it would be great to always remember the patient’s point of view. While it can’t be confirmed that provider mistreated them due to their weight, a patient should never leave an office visit feeling disrespected for any reason.  [Some passages altered for identifying factors and to keep the content related to obesity]

1) I last saw a Dr about six months ago. He was the perfect example of robust health. I look to be the polar opposite of him. He ignored everything I said gave me some exercises to do and left. His demeanor was condescending and aloof. I have not been back nor will I.

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2)  I had a doctor once tell me “put the fork down,” instead of running blood work for a genetic problem that’s caused everyone in my family to become grossly overweight. I went to see them because over the course of a few months had become horribly tired all the time, had issues with my monthly visitor, started noticing my skin was getting grey-ish and I was gaining weight when I was usually quite active and hadn’t changed eating habits. It’s horrible how they treat people that are overweight.

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3) I went in to ask to get my thyroid tested and she {my doctor} was an ass. I was trying to talk to her about it and she said “I’ll order the test but I don’t get paid to discuss nutrition with you”…I was trying to talk about my inability to lose weight {along with other symptoms} despite my restrictive diet and working out 3 times a week…

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4) I had a doctor (a back-up doctor, not my regular doctor) who seriously thought that all she had to do was point to a red dot on a height-weight chart and glare at me for a few seconds and I would magically become thin. I’d tell her, “I know I’m fat, but you pointing to that chart doesn’t make me thin. I know I should eat less, but I’m hungry all the time. So, give me a pill that makes me less hungry, or tell me what to eat so that I won’t be so hungry.”

She was absolutely no help whatsoever. I had to figure it all out myself – through relentless self-experimentation along with trial-and-error. (Hint: a lot of the foods which made me less hungry turned out to be nutritionally-dense whole-foods which were high in natural fat and quality protein).Eventually I lost about 40 pounds. And I see this same doctor. And I’m all excited about my progress. And she points to another red dot on the same damn height-weight chart, about 2 inches away from the previous red dot, and glares at me just as much as before.

So I show her my belt, which has about 12 notches cut into it from all the lost weight, and I show in my medical file how I used to weigh a lot more. She leaves the room, and this time she comes back with a photocopy of the USDA Food Pyramid and some advice on chewing more slowly. Now, I’ve lost even more weight – 87 pounds in total, and I’ve been taken off 80% of my meds, and the doctors are amazed. I’m sure she’ll take full credit for my health improvements, and get a fat bonus for all of that work she did, pointing at a red dot and Xeroxing the Food Pyramid

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5) 2 years ago, I went to my doctor. I couldn’t understand why I kept gaining weight while eating a low (no) fat vegetarian/vegan 1200 calorie diet. I did everything by the book. Ate little and burned 500 cal/day on the elliptical and I still gained. She asked me how heavy I was, then she asked how tall I was. She calculated my bmi and said:”your bmi is high enough for a gastric bypass”.

She didn’t say she felt for me, she didn’t listen to the fact that I already ate little calories. She just assumed that I was lying, ate too much and that limiting the size of my stomach would be the best option. It seriously was the first thing she said to me after I sat there telling my story in frustration and tears. I then went a little crazy and yelled at her that she was the most incompetent person I had ever come across and left her office to never return. I don’t go to doctors anymore. Not for advice anyway.

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6) Frequently. For most of my life, the fact I could walk several miles without tiring, could lift-and-carry 100-200 pounds, but couldn’t run a quarter mile without my lungs seizing meant I was “out of shape and fat,” not asthmatic. Funny. I can even jog, if I get to take my inhaler. I’ve not had an inhaler of my own for long, about a year — I still remember the first time I had my very own inhaler. I was 1) giddy from oxygen as it was a nasty bout of bronchitis, 2) I cried for a couple of hours out of sheer relief-joy. No longer did I have to hope/beg to borrow an inhaler from my sisters or a friend.

I didn’t know that a five mile walk or a quarter mile jog wasn’t supposed to take two days to recover one’s breathing, only 5-10 minutes to “catch my breath.” But — despite having a sympathetic pulmonologist who has heard me on a bad day — I still have a couple of doctors who sneer at me, and tell me I don’t REALLY have asthma, or I don’t REALLY have an ear/sinus infection, I just need to lose fifty pounds…

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7) Not only do some doctors have a prejudice against fat patients, they automatically assume that 1) the fat is YOUR fault and 2) because you’re fat, you must be sick (diabetic, etc). My daughter’s doctor is notorious for this. She even had me go get blood work done on her. Being a concerned mom, I was worried that something was really wrong. After all, doctor knows best, right? Wrong. Her blood work came back perfectly healthy. 

I think a lot of doctors forget that THEY work for US. Some are really arrogant. But I, too, live in a small town. So, if a doctor doesn’t do something the patients like, the patients will talk. It’s nothing to hear a group of mothers/parents talk about which doctors they like and which ones they don’t.

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8) I was fortunate in that when I was told I needed to lose weight I already knew that LCHF worked for me, my problem was just doing it, all my doctor really did was have the nurse hand me some Xerox’d sheet telling me to eat less fat

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9) My ob/gyn, yesterday, blew me off. The VERY first thing out of her mouth was “you’re fat, and you need to change your diet.” She did not, in any way, shape, or form, ask me what is a normal day’s worth of meals for me. [The sneer and look she gave me, quite full of disgust, indicated she has the belief I only eat fast food/junk food. Grr.]…

…I’m getting very, very tired of the memorized rote script doctors, who cannot accept patients are individuals, and might actually KEEP RECORDS and DATA of their own, and might actually have more than one doctor. If I wanted a completely useless answer in response to a question, I would call Dell’s tech support in India. It’d certainly be more -amusing-. Needless to say, I won’t be going back to her. She doesn’t appear to value my -life- more than the fact I’m fat.

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10) As a patient I hope whoever I see understands I am in front of them so I can improve my health. My hope is that he/she is open minded and willing to listen to what I have to say understanding that just because I have no titles after my name I am knowledgeable enough to take part in improving my health. Most often what I encounter are busy people with huge workloads that stereotype people while making a snap judgement.

By the time I see someone I have waited for 2-4 hours passed tons of bureaucratic hurdles and exhausted my patience. I always feel rushed when I am talking to any primary care nurse or physician. I try and cover everything about why I am in front of that person in the 5-10 minutes we have. It never works out well for either of us. Having tried this many times over the years I have simply given up. I find it easier to work on my health alone.

Summary: This post explored additional issues on clinician perspective in dealing with issues on obesity. Patients are more than just calories in and calories out. Using this model to calculate and make assumptions about a patient’s lifestyle is detrimental for both the provider and patient – leading to both parties being frustrated at one another. 

References:

1) http://www.nytimes.com/2010/09/16/health/16chen.html

2) Ebbeling, C. B., Swain, J. F., Feldman, H. A., Wong, W. W., Hachey, D. L., Garcia-Lago, E., & Ludwig, D. S. (2012). Effects of Dietary Composition During Weight Loss Maintenance: A Controlled Feeding Study. JAMA: the journal of the American Medical Association307(24), 2627.

 

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