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.

 

Perspectives on Obesity Between the Clinician and Patient Pt.1

As healthcare providers, we often spend more time focusing on the cardiometabolic effects of obesity and forget about the psychologic aspects. It should be obvious to anyone in America that there is a huge prejudice against the overweight/obese in society. This isn’t surprising, but you may be surprised to find this same sort of prejudice in the clinical setting – a place where patients expect their clinicians to treat them with empathy and respect.

For example, primary care providers were asked about their attitudes on the obese (defined as BMI > 40 in one sample and BMI > 30 in the other to see differences in attitude related to BMI). What did they find? [1]

More than 50% of physicians viewed obese patients as awkward, unattractive, ugly, and noncompliant…Primary care physicians view obesity as largely a behavioral problem and share our broader society’s negative stereotypes about the personal attributes of obese persons.

Surprisingly, we found few differences based on physician characteristics (including BMI and gender) or how obesity was defined in the survey. Among those that were detected, the mean differences were very small, raising doubts about their clinical significance.

This perspective may even be more prevalent in younger primary care providers: [2]

We found higher prevalence of negative attitudes toward obese patients than reported by others. For example, almost 80% of our respondents reported that patients frequently or almost always lacked discipline, and 52% felt patients lacked motivation to lose weight.

The high prevalence of negative attitudes may hinder primary care physicians from discussing weight loss with extremely obese patients. It was interesting that older age and higher patient volume were independently associated with less negative attitudes. Perhaps, physicians with more experience or who are more successful develop a “tolerance” toward patients with extreme obesity.

There was a high prevalence of negative attitudes, particularly in younger physicians and those with lower patient volume. Increased knowledge of weight-loss diets was associated with less dislike in discussing weight loss (P < 0.0001), less frustration (P = 0.0001), less belief that treatment is often ineffective (P < 0.0001), and less pessimism about patient success (P = 0.0002)…further research is needed to determine if interventions to increase knowledge of physicians will lead to less negative attitudes toward weight loss and extremely obese patients.

It’s hard to say why some clinicians may feel this way towards the obese. Do the negative attitudes occur because of societal beliefs? Or do they occur due to frustration at not seeing weight loss from patients after intervention? I would argue it’s a combination of both with one belief reinforcing the other. However, is the difficultly in helping patients lose weight really a result of low “will power” or “discipline?” Perhaps providers have the wrong beliefs about causes of obesity in the first place – which influences the interventions they are likely to tell their patients. From the first study on primary care provider beliefs:

 Physical inactivity (mean rating of 4.3) was rated significantly more important than any other cause of obesity (p < 0.0009). Two other behavioral factors—overeating and a high-fat diet— received the next highest mean ratings (3.9 and 3.8, respectively; 3, moderately important; 4, very important; 5, extremely important).

So primary care providers seemed to rate physical inactivity as the leading cause of weight gain in obesity. It definitely is true that exercise can help a person lose weight, but exercises’ effect on weight loss is more dramatized than reality. In Identifying the difference between exercise + diet versus diet alone in randomized control trials by the Cochrane Collaboration, the difference with the addition of exercise was: [3]

In the group exercise plus diet versus diet alone fourteen trials involving 1049 participants included data regarding weight loss that were suitable for meta-analysis. Participants in both groups lost weight across trials. The pooled effect for interventions with a follow-up between 3 and 12 months was a reduction in weight of 1.1 kg (95% confidence interval (CI), 0.6 to 1.5) in the exercise and diet group compared with the diet alone group.

So the difference these RCTs found with the addition of exercise + diet versus diet alone was an average of 2.4 lbs lost in favor of exercise with diet. Again, the addition of exercise does help with more weight loss but hardly the amounts that all those late night exercise gadget infomercials portray. This is not to say that one shouldn’t bother with exercise if they are already eating right – exercise has other obvious benefits.

Going back to the study on primary care provider attitudes on obesity, you’ll notice that the next two highest rated beliefs providers have on causes of obesity are: overeating and a high fat diet. One of these points is not supported by the literature. If you look at the National Health and Nutrition Examination Survey (NHANES) from the CDC you’ll see this:

Image From Dr. Feinman

Image From Dr. Richard D. Feinman professor of biochemistry at SUNY

It is definitely true that both Men and Women are eating more calories since the 80’s…but is it from a high fat diet? Men have actually decreased their total fat and saturated fat calories while women have increased both. However, both men and women have increased their dietary carbohydrate by vast margins at + 23.4% and + 38.4% respectively! If one is to believe a high fat diet is one of the independent causes of obesity, how can they discount the increase in carbohydrate as a factor as well?

Additionally, the increase in carbohydrate consumption likely contributes to the increases in overeating/calories. This requires a paradigm shift from viewing a calorie is a calorie and focusing on the hormonal, physiologic and psychologic effects that macronutrients have on the body and mind. By doing so, we can see that a patient’s inability to lose weight has nothing to do with a lack of discipline, laziness or willpower to reduce/count calories. Instead, it may just be that they’ve been receiving the wrong advice in the first place.

BTW, before this post ends, it should also be pointed out that negative attitudes/beliefs to the obese applies to clinicians from the patient’s perspective as well. From a study last month: [4]

Respondents reported more mistrust of physicians who are overweight or obese, were less inclined to follow their medical advice, and were more likely to change providers if the physician was perceived to be overweight or obese, compared to normal-weight physicians who elicited significantly more favorable reactions.

These weight biases remained present regardless of participants’ own body weight. Stronger weight bias led to higher trust, more compassion, more inclination to follow advice, and less inclination to change doctors when the physician was presented as normal weight. In contrast, stronger weight bias led to less trust, less compassion, less inclination to follow advice and higher inclination to change doctors when the physician was presented as obese.

This study suggests that providers perceived to be overweight or obese may be vulnerable to biased attitudes from patients, and that providers’ excess weight may negatively affect patients’ perceptions of their credibility, level of trust and inclination to follow medical advice.

At the end of the day, after all this talk of health and weight, let’s just treat individuals as individuals irrespective of their weight.

 Summary: The prejudice that the obese face in society is very prevalent, but this negative attitude may also be present in the healthcare setting from clinicians. It’s hard to say if these attitudes from clinicians originated with the same prejudice from society in general, or if they are from clinicians developing negative attitudes due to lack of success in treating their obese patients. Interestingly enough, patients have negative attitudes about their providers if the provider is obese. In the end, let’s just get respect one another whether a person is obese or not.

ObeseAttitudes

1) Foster, G. D., Wadden, T. A., Makris, A. P., Davidson, D., Sanderson, R. S., Allison, D. B., & Kessler, A. (2003). Primary care physicians’ attitudes about obesity and its treatment. Obesity Research11(10), 1168-1177.

2) Ferrante, J. M., Piasecki, A. K., Ohman-Strickland, P. A., & Crabtree, B. F. (2009). Family physicians’ practices and attitudes regarding care of extremely obese patients. Obesity, 17(9), 1710-1716.

3) Shaw, K., Gennat, H., O’Rourke, P., & Del Mar, C. (2006). Exercise for overweight or obesity. Cochrane Database Syst Rev4.

4) Puhl, R. M., Gold, J. A., Luedicke, J., & DePierre, J. A. (2013). The effect of physicians’ body weight on patient attitudes: implications for physician selection, trust and adherence to medical advice. International Journal of Obesity.

How You Know Things Aren’t Changing

Picture by Glane 23

By now you may have heard that McDonalds is introducing a healthier yolk-less Egg McMuffin. This of course will do nothing in promoting health since dietary cholesterol, as previously mentioned, has very little to do with serum cholesterol. However, while the claims of health from this new McMuffin are likely to be bunk, the fact that this new sandwich was developed tells us a lot about our existing paradigm; mainly that it hasn’t changed.

McDonalds is one of the most successful companies on the planet and there is no doubt that they must have spent considerable amount of research before the launch of this new McMuffin. Using this new sandwhich as a surrogate, it’s reasonable to conclude that the world still fears dietary cholesterol and believes it is related to heart disease. Not only is dietary cholesterol still feared, but the response online criticizing this move from McDonalds reveals other paradigms still in existence:

McDonald’s says its new Egg White Delight (ugh, even the name seems like a late-in-the-day boardroom compromise) clocks in at 250 calories, according to CNN. But holding the yolk only cuts the calorie count by 50…an original Egg McMuffin has 300 calories. True, without the yolk you’ll skip the cholesterol, but the white cheddar and Canadian bacon will still give you a wake-up call of fat.

And from the CNN Link:

McDonald’s (MCDFortune 500) will release the Egg White Delight, an egg white version of the Egg McMuffin breakfast sandwich, nationwide on April 22, said company spokeswoman Danya Proud.

The new sandwich, which contains bacon and white cheddar on a whole grain English muffin, totals 250 calories, according to Proud. That’s compared to the classic Egg McMuffin, which has 300 calories. She added that egg whites will also be offered on the other breakfast sandwiches sold at McDonald’s.

According to the U.S. Department of Agriculture, an egg yolk contain 5 grams of fat, 2 grams of saturated fat and 213 milligrams of cholesterol, as well as 60 calories, Egg whites, however have no fat or cholesterol, and 15 calories. The USDA recommends that egg yolk consumption should be limited to four yolks per week.

So not only is the paradigm of dietary cholesterol reinforced, but also the paradigm of “a calorie is a calorie” and the paradigm on the horrors of dietary fat. Sad times and a reminder on how far we still are from changing our current knowledge of what really causes heart disease, obesity and diabetes.

Cat Obesity On The Rise…Similar Pathway To Humans?

TheFatNurse just saw this video….WUT

Apparently pet obesity is on the rise with as many as 53% of dogs and 55% of cats being overweight/obese. This increase in weight increases their risk of arthritis, diabetes and cancer…just like HUMANS…

So what does the news report recommend for these overweight pets? Talk to your vet, start an exercise program and choose…A LOW FAT DIET PLAN…WUT…just like HUMANS…The focus of the news story was on an overweight cat being put on a michael phelps exercise regiment and low fat diet plan. The results? SUCCESS, according to the owner, because the cat lost 1 lb… in 6 months. The parallels to the frustration of human obesity are almost an exact match.

Now TheFatNurse is far from an expert on cat physiology…but some vets are suggesting that cats drop the carbohydrates

Diabetes is one of the most common feline endocrine diseases and, while we do  not know all of the causes of this complex disease, we do know that many diabetic cats cease needing insulin or have their insulin needs significantly decrease once their dietary carbohydrate level is lowered to a more species-appropriate level than that found in many commercial foods

WUT…

Feeding a high carbohydrate diet to a diabetic cat is analogous to pouring gasoline on a fire and wondering why you can’t put the fire out.

The so-called “light” diets that are on the market have targeted the fat content as the nutrient to be decreased but, in doing so, the pet food manufacturers have increased the grain fraction (because grains are always cheaper than meat), leading to a higher level of carbohydrates.

cats tend to overeat when free-fed high carb dry food.  The first reason is because the pet food manufacturers do not play fair when manufacturing dry food.  They coat the kibble with extremely enticing animal digests which makes this inferior source of food very palatable to the target animal.

…Carbohydrates do not seem to send the “I’m full and can now stop eating” signal to a cat’s brain like protein and fat do.

The third reason why some cats overeat is boredom.

Wow sounds like they go into the food palatability and hormonal obesity regulation theories of obesity there! This post is merely food for thought because using data from animals for human evidence (even tho early scientist did this by declaring dietary cholesterol leads to heart attacks by feeding cholesterol (an animal product) to rabbits (Herbivores) who then developed heart disease) is not always applicable. Especially so in this case since cats are oligate carnivores while humans are omnivores. Alright enough about cats, TheFatNurse just found it interesting that similar controversies about carbohydrates and chronic disease exists for humans as well as cats.

picture from pandawhale.com

 

National Cholesterol Awareness Month and Alcohol Policy to Solve Obesity?

Did you know that September is National Cholesterol Awareness Month? Via our US Department of Health and Human Services:

September may be “back to school month”, but it is also Cholesterol Awareness Month. Take a few moments to study up on this important health issue.

Yes sir! They were kind enough to even link a PDF pamphlet that you can give to all your friends and family. It has handy tips like:

Diet. Saturated fat and cholesterol in the food you eat make your blood cholesterol level go up. Saturated fat is the main culprit, but cholesterol in foods also matters. Reducing the amount of saturated fat and cholesterol in your diet helps lower your blood cholesterol levels

Err…wait a minute…story is a little more complex than that man!

Other tips include eating a:

a low- saturated-fat, low-cholesterol eating plan that calls for less than 7 percent of calories from saturated fat and less than 200 mg of dietary cholesterol per day…Foods low in saturated fat include fat-free or 1 percent dairy products, lean meats, fish, skinless poultry, whole grain foods, and fruits and vegetables. Look for soft margarines (liquid or tub vari- eties) that are low in saturated fat and contain little or no trans fat (another type of dietary fat that can raise your cholesterol level). Limit foods high in cholesterol such as liver and other organ meats, egg yolks, and full-fat dairy products.

Looks like it’s the same old story. If you’ve followed this blog or some of the other people in TheFatNurse’s links, you’ll know the story is way more complex and these diet guidelines may not work for everyone. Saturated fat’s relationship with heart disease is definitely debatable and cholesterol absorption from dietary factors may not have a significant effect on serum cholesterol. In addition, cholesterol as a predictive marker may not even be that accurate in predicting risk for certain people. Perhaps a better (and more informative yet light) way is to spread the cholesterol knowledge through TheFatNurse comics!

Another interesting report from last month that TheFatNurse didn’t see until now is from the CDC via RAND regarding the use of alcohol control policies in controlling obesity and it’s related diseases. They are proposing hypothetical solutions in controlling obesity through similar measures taken in regulating alcohol in the states. The report is aware of the potential controversy that such measures would face:

However, alcohol policies, especially those seen to infringe on individual choice (such as restrictions in outlet density) or to negatively affect moderate drinkers who do not cause harms (such as excise taxation) have been controversial. Over time, many of these measures have become widely accepted and do work in curbing problems related to alcohol use.

In otherwords, people will be upset at having their food choices regulated in order to control obesity…but its for their own good and they’ll get use to it! So what are some ideas? Below is a table from the report. The left column is the alcohol related control policy and how it could be translated to an obesity food regulation policy:

Wow…some of this stuff can look pretty extreme. You’ll see that “fat” foods are targeted. Perhaps before making all these regulatory theories one should question whether dietary fat is a cause of obesity in the first place?

Bottomline: It’s national cholesterol awareness month but the Dept of HHS seems to be putting out the same ol same ol on cholesterol and heart disease. Additionally, some reports are discussing potential ways to control obesity through hypothetical regulations derived from alcohol regulation. As seen with the knowledge on cholesterol, without a true consensus on what causes obesity and it’s related diseases, is food regulation really that wise of a choice? Let’s work on getting the message out on dietary fat and cholesterol beyond fat & LDL cholesterol = bad and HDL = good before working on policies that could potentially cause more harm than good.

Interesting New Meta Analyses Out on BP and Low Carb. Response from Egg Study

In case you haven’t heard, last week the Cochrane Hypertension Group released some compelling updates on Blood pressure medications (1). But before we get to that, you may be wondering what the heck the Cochrane Collaborative is. While TheFatNurse can’t comment on all nursing schools, during TheFatNurse’s time as a wee little nursing student, one of the buzzwords was Evidence Based Practice in school. As a result, one of the organizations to help increase the use of evidence based practice is the Cochrane collaboration.

The Cochran Collaboration consists of over 28,000 volunteers in more than 100 countries that saw a need to organize the medical literature in a way that was easy to understand and evaluate. The goal is to allow evidence based practice to make its way into the healthcare setting. They go about doing this through systematic reviews of randomized control trials. So what did they findout about hypertension and blood pressure?

The Cochrane group set out to see what the literature showed about individuals with anti hypertension medications and mild hypertension (systolic of 140-159 or diastolic of 90-99) but no prior related issues involving cardiovascular diseases/events. They wanted to examine Randomized Control Trial studies that had at least 1 year duration. Specifically, the outcomes from the literature they were examining were all hypertension related such as coronary heat disease, stroke, mortality, total cardiovascular events and adverse effects from medications causing withdrawals. So what did they conclude? In the author’s own words:

In this review, existing evidence comparing the health outcomes between treated and untreated individuals are summarized. Available data from the limited number of available trials and participants showed no difference between treated and untreated individuals in heart attack, stroke, and death. About 9% of patients treated with drugs discontinued treatment due to adverse effects. Therefore, the benefits and harms of antihypertensive drug therapy in this population need to be investigated by further research.

Pretty interesting. Another new study out last week was a meta analysis on low carb diets (2). Here were the results:

A total of 23 reports, corresponding to 17 clinical investigations, were identified as meeting the pre-specified criteria. Meta-analysis carried out on data obtained in 1,141 obese patients, showed the LCD to be associated with significant decreases in body weight (−7.04 kg [95% CI −7.20/−6.88]), body mass index (−2.09 kg m−2[95% CI −2.15/−2.04]), abdominal circumference (−5.74 cm [95% CI −6.07/−5.41]), systolic blood pressure (−4.81 mm Hg [95% CI −5.33/−4.29]), diastolic blood pressure (−3.10 mm Hg [95% CI −3.45/−2.74]), plasma triglycerides (−29.71 mg dL−1[95% CI −31.99/−27.44]), fasting plasma glucose (−1.05 mg dL−1[95% CI −1.67/−0.44]), glycated haemoglobin (−0.21% [95% CI −0.24/−0.18]), plasma insulin (−2.24 micro IU mL−1[95% CI −2.65/−1.82]) and plasma C-reactive protein, as well as an increase in high-density lipoprotein cholesterol (1.73 mg dL−1[95%CI 1.44/2.01]). Low-density lipoprotein cholesterol and creatinine did not change significantly

Again, very interesting stuff. Also David Spence, the author behind the egg yolk as deadly as cigarette smoking study (as some in the media dubbed it), responded to Nutritionist Zoe Harcombe’s critique of his study in her blog’s comments. Just scroll down until you find it.  It’s a good debate between Dr. Spence and Zoe Harcombe.

Picture by Coldbourne from ClipArt. Creative Commons Attribution-Share Alike 3.0

TheFatNurse hopes this is where the future of research is heading towards where debate can occur openly and freely for people to observe and put in their analysis. What would make this better is if all studies were open to the public and not just the abstracts. For example, the two studies TheFatNurse mentioned are not accessible with TheFatNurse’s university account which means TheFatNurse and others can only rely on the abstract to see what the study is about. This is a start, but the abstract tells us nothing about the details on how the experiment was setup, potential confounding factors and other information to allow an honest critique. By having open debate, it’ll be much more productive in moving towards the truth and confirming the validity of studies whether they are for or against the existing paradigm of fat.

References:

(1) Pharmacotherapy for mild hypertension

  1. Diana Diao1,*,
  2. James M Wright2,
  3. David K Cundiff3,
  4. Francois Gueyffier4

Editorial Group: Cochrane Hypertension Group

Published Online: 15 AUG 2012

Assessed as up-to-date: 1 OCT 2011

DOI: 10.1002/14651858.CD006742.pub2

(2) Systematic review and meta-analysis of clinical trials of the effects of low carbohydrate diets on cardiovascular risk factors

  1. F. L. Santos1,
  2. S. S. Esteves2,
  3. A. da Costa Pereira3,
  4. W. S. Yancy Jr4,5,
  5. J. P. L. Nunes3,*

Article first published online: 20 AUG 2012

DOI: 10.1111/j.1467-789X.2012.01021.x

Seinfeld Falls For The Old Fat Hypothesis

TheFatNurse recently jogged down memory lane in the 90’s with a few episodes of Seinfeld. You can only imagine TheFatNurse’s delight when an episode about low fat yogurt plopped onto the screen – CAPTURES THE PERSPECTIVE OF FAT SO WELL IN THE FATNURSE’S CHILDHOOD!

Photo by Alan Light; CC 2.0

While the belief that fat is evil still persists today, it was much much worse in the 1990s and this seinfeld episode captures it perfectly:

http://yadayadayadaecon.com/clip/46/

The episode shows Seinfeld and Elaine ecstatic about a new yogurt shop serving non fat yogurt. Both characters can’t believe there is no fat and proceed to gobble down cups and cups only to be shocked when they end up packing on the pounds. It’s revealed that the non fat yogurt actually has some fat in it which is what’s causing the weight gain. Mayor Rudy Giuliani even weighs in on the evils of fat in the non fat yogurt.

TheFatNurse is pretty sure the characters were getting fat not from over indulging in just fat, but also sugar. Even if the yogurt was 100% fat free, the characters would still have gained weight from eating so much yogurt with sugar under the belief that its ok because there is no fat. Look at the nonfat yogurt from Costco: 52 grams of sugar!

It’s a sad reminder of how TheFatNurse grew thinking fat consumption worked. This paradigm that eating fat makes one fat and eating sugar is ok was also shared by a lot of TheFatNurse’s friends growing up. In fact, TheFatNurse even remembers having an old friend who use to indulge in sherbert and yogurt while TheFatNurse ate full fat ice cream because TheFatNurse’s friend didn’t want to get fat…well guess what happened to her?

SHE’S DEAD

…dead emotionally to TheFatNurse that is. Cause we had a falling out but otherwise her health is probably ok.

Anyways, on a related note, a new study (observational study) came out from the Journal of American Board of Family Medicine showing the dangers of obesity may be against what society believes using data from 2000-2006. It’s not the obesity that is causing mortality but the diseases that are associated with it like diabetes and hypertension.

Regarding severe obesity, as in the relatively fewer prior studies examining this category separately,1519 this study found it to be associated with significantly increased mortality risk without adjusting for diabetes or hypertension. However, severe obesity was no longer significantly associated with mortality after adjusting for these conditions, something not examined in the prior studies. Considered in the context of prior studies, these findings suggest that the mortality risk of above-normal BMI, at least in the short term, may be lower in the current era than in the past.

…suggest that efforts to reduce mortality among the overweight and obese might be targeted most productively at individuals with coexisting diabetes, hypertension, or both.

Nice that the study reminds readers that generating conclusions from an observational study is not the same as RCTs!

Given the observational nature of the current analyses, these notions represent hypotheses to be tested in randomized controlled trials.