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Listen to Your Patients



One of the benefits of taking a few days off and reposting old posts is that I get to reread and review some of the previous comments. I also receive new comments on old posts and see that not much has changed.

Although, I do not generally respond to most comments, I read all of them and, unless they are clearly defamatory or thinly veiled promotions for commercial weight loss scams, I let them pass.

In fact, for me, reading the comments to my posts is the most rewarding part of writing this blog. I’d be the first to admit that reading these comments (like listening to my patients) has thought me more about obesity than any textbook or research article.

Indeed, if nothing else, the comments reassure me that many of the topics I choose to write about are indeed relevant to the patients we are trying to serve.

Here is just one example of a comment that one reader (TinaUK) sent me in response to a post on weight bias:

“I was constantly frustrated by visits to doctors which involved me being lectured about my weight; disbelieved when I told them the problems I was having; having health issues constantly being put down to weight issues; gaining weight while following their advice, but having them disagree that what I said was happening was happening and the general failure to take my issues seriously enough to investigate them properly.

I was told to eat a low fat diet which I had been doing for some time. I was told to get exercise when I was going to the gym 3 times a week and walking 4 miles most days. I was told that the pain I experienced in my lower legs when walking was due to the female skeleton being inferior for walking purposes and that extra weight was compounding this ‘fact’. I was tired all the time and hungry too. My stress levels were very high and I believe that I may have been suffering from PTSD (never investigated despite enough information being available to indicate that this was a reasoable thing to look into).”

This comment highlights a number of the issues that I so frequently write about:

1) We should never assume that any complaint in an obese person is simply because of their weight.

2) We should not advise patients to just eat healthier and be more active without first taking a proper history of current eating or activity behaviour.

3) We should always make sure we properly assess and address the key drivers of weight gain (in this case fatigue, pain, stress, PTSD?)

Only too often, do we discount the information that our patients readily give us and jump to simplistic and ineffective ‘eat-less-move-more’ (ELMM) strategies.

Obviously, giving useless ELMM advise and then blaming the patient when it does not work is a lot easier than taking the time to fully assess and address issues like chronic fatigue (sleep apnea?), pain (fibromyalgia?), stress (time management? workaholism? ADD?), or PTSD.

Assessing and addressing the latter takes time and requires listening carefully to your patient.

Remember, obesity is a ‘sign’, overeating is a ‘symptom’.

AMS
Edmonton, Alberta

5 Comments

  1. This is a very interesting topic. Not only for “assessment” but also “to engage patients” in treating their chronic condititions, it’s important to listen to our patients. Recently I found “Mind the gap”, a blog by Stephen Wilkins, about doctor-patient communication in primary care.

    http://healthecommunications.wordpress.com.

    He’s writing some posts to think about as careprovider.

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  2. While I deeply regret the fact that so many physicians do not listen to their patients and heartily agree with you that this must change, I must take exception to your final sentence: Remember, obesity is a ’sign’, overeating is a ’symptom’.

    The problem goes far beyond simply not listening. In many cases, physicians simply do not believe their patients and continue insisting that the patients are overeating when in fact this is often not the case. As you yourself have so eloquently expressed on numerous occasions, ELMM is simplistic and often downright useless and/or counterproductive. There are many reasons why people are overweight–overeating does not always play a part, despite what mainstream medicine and the media continue to trumpet.

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  3. These comments are the most common I hear when patients come to me for weight management counseling. In all fairness to doctors (I am not a doctor), it takes me at least 6-10 hours of patient history taking, physical assessment, nutrition behavior assessment, metabolic testing and patient discussion before I would begin to assertain a primary weight management plan.

    I don’t know a doctor with this kind of time to devote to a patient before giving advice or medication or a referral. It’s a tall order.

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  4. I can’t afford drugs, therapy, or surgery.
    So I’m on a DIY ELMM program.
    Nothing boot camp.
    I’m losing 1 pound a week on average, for 40 pounds so far.
    But there’s this nagging Dr Sharma voice in the back of my head saying “ELMM is doomed to fail”.

    I can’t get expensive medical treatments. if my obesity was caused by lifestyle, only a lifestyle change will fix it anyway.
    ELMM is all I’ve got.
    So how about some real research on ELMM – it does work for some people, even if it doesn’t work for everybody , all the time.
    I bet there are many people out there who use bouts of ELMM when they find their weight going up, get back to a good weight – and never ever show up in an obesity clinic. So obesity researchers miss them.

    As long as there’s no other choice, people will use commercial programs, or DIY. It would be nice if there was research on optimal diet (beyond just “eat less”, or worse, dietitians who insist people have to eat a lot to stay healthy even if that means they stay fat – if someone sick enough to have bariatric surgery can eat miniscule amounts, a healthy person can survive on a moderate calorie deficit.), and exercise (not just “move more”).

    In the meantime, it’s individual trial and error for us DIYers.
    Ignoring that nagging that ELMM is futile, doing what we can.

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  5. You know, I actually agree with Anonymous. ELMM does ‘work’ to some extent for a lot of people, and very well for a few. Tweeking habits can result in a bit of weight loss for most, and it’s not always impossible to maintain the changes, although there seems to be evidence that weight tends to creep back up in a lot of people even if the changes are maintained. It does seem like a complex issue that needs further study.

    On the other hand, if it weren’t for the weight bias in society, then most people would agree that level of fitness is many times more important for health and quality of life than weight or BMI, and maintaining a reasonable level of fitness is a hell of a lot easier than maintaining a weight loss.

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