A few days ago I posted an article with the tongue-in-cheek rhetorical title, “Is there a role for dietitians in obesity management?”, to which, as readers should note, my clear answer (or so I thought) was “ABSOLUTELY!”.
Interestingly, the response to this post from the dietitian community was both humbling and indeed an honour. Not only did the post receive an unusually large number of lengthy and passionate comments (both here and on social media), but I also received a most thoughtful letter signed by well over 200 dietitians, suggesting I reconsider or at least clarify my post.
This overwhelming response to my post was humbling, because, I do not believe that there is anything I could possibly have written that would have elicited an even remotely similar prompt and passionate response from my own medical colleagues – clearly dietitians care strongly about what they do. Apparently, they also appear to pay attention to what I have to say – which is an honour indeed!
That said, I agree very much that some clarification is in order.
For one, as stated above, the title of the post was indeed entirely rhetorical – if I did, for even a second, have any doubts as to the important role that dietitians have in obesity management, I would probably not have bothered writing the post at all.
Secondly, I would have thought that both my opening and closing paragraphs would have made it entirely evident just how much respect I have for the professional expertise that dietitians have with regard to their discipline and their essential role in obesity management. I truly believe that it would be entirely fair to say that dietitians’ knowledge of biochemistry, disease processes, counseling techniques, client-centred care, and clinical passion are second to none (and I happily include my own colleagues in the comparator).
Furthermore, nowhere did I state or imply that my comments apply to ALL (or even the majority of) dietitians – in fact, I thought I had made it clear that the issues I raised applied to a small minority (perhaps no more than a handful?) of dietitians. (I did not single out anyone by name, as I do not believe in, nor intended, any ad hominem attacks).
In my post, I touched on a few different but related issues:
1) The unequivocal endorsement of obesity as a chronic disease.
2) Potential gaps in specific obesity training.
3) Reluctance (of at least some practitioners) to consider weight loss as a realistic (and often necessary) therapeutic option.
Apart from the fact (as I have done in countless previous posts) that I have called out members of my own (or for that matter, any) medical profession on the exact same issues, I am also fully aware that within any health profession there is a wide range of expertise, experience, and opinion on virtually any issue.
But, I do believe that each of the above-mentioned issues is of importance (not just for dietitians), and I will happily clarify my stance and thinking on each of them in subsequent posts.
As to why, if my comments apply to all health professions, I decided to single out dietitians for this particular post, the reasons are simple:
1) This specific post happened to be prompted by actual conversations over the past few months with several dietitians from across Canada, who all (independently!) raised similar concerns about what they thought was perhaps amiss amongst some (younger?) members within their profession when it comes to obesity management (again, no names!).
2) Ten years of blogging have taught me that to initiate a lively discussion with any post, it needs to be opinionated, one-sided, strongly worded, and provocative – anything less, is a waste of time (sadly, balance is boring!). If nothing else, my post certainly achieved that.
3) I truly do consider the role that dietitians have to play in obesity management of the utmost importance. Dietitians are in fact “THE” profession, that other health professionals most often look to when it comes to obesity management. With that comes immense responsibility, which I know dietitians take very seriously.
I promise that I will attempt to do my utmost to clarify and expand on the specific issues raised in my previous post in subsequent posts.
Hopefully these “clarifications” will be taken in the respectful and constructive spirit in which they are offered – I am fully aware that nothing in medicine is black and white; we all happily operate in shades of grey (as I always emphasize to my patients). I’m also very aware that today’s certainties may well turn out to be yesterday’s follies – as our understanding of disease processes and treatments evolve, so do our clinical approaches (as they should).
All I ask of you, is to bear with me…
Unfortunately, not much has changed.
This sorry state of affairs is now discussed by James Colbert and Sushrut Jangi in a Perspectives piece in the New England Journal of Medicine.
As the Colbert and Jangi note,
“Physicians-in-training frequently fail to recognize obesity, are unfamiliar with treatment options, and spend relatively little clinic time treating obesity.”
As I have previously suggested, all physicians-in-training need a rigorous background in the biological and pathophysiological foundations of obesity.
“Once trainees have achieved a solid foundation in the science of obesity, these fundamentals must be applied clinically through mastery of behavioral medicine.”
“Finally, successful management of obesity requires that students learn to function as members of interdisciplinary care teams that include physicians, nurses, medical assistants, social workers, nutritionists, and behavioralists; the earlier such collaborative models are introduced into medical education, the more likely they will be to successfully replace the antiquated model of the solo physician and patient.”
While Colbert and Jangi note the importance of educating physicians in nutrition and motivational interviewing, I would take that this is far too “nutrition-centric” a view of what is needed.
Although, more education in nutrition and physical activity during physician training could certainly not hurt, we need to ultimately move beyond the age-old “eat-less-move-more” paradigm of obesity management. Not only, has this approach failed our patients, it also fails to acknowledge the complex physiology and psychology of obesity.
Thus, I would suggest that even the most knowledgeable “nutrition doctor” will more often than not end up treating the “symptoms” and not the “root cause” of obesity.
So, while I am all for teaching medical students the basics of obesity management (indeed, I would go as far as to fail any trainee, who does not know the fundamentals of energy physiology and the neuroscience of ingestive behaviour), propagating a “lifestyle” approach to obesity management will do little more than reinforce the notion that obesity is simply a matter of motivation and choice.
Health professionals, who still believe that obesity can be conquered simply by teaching and motivating people to eat healthy, are sadly part of the problem rather than part of the solution.
Colbert JA, & Jangi S (2013). Training Physicians to Manage Obesity – Back to the Drawing Board. The New England journal of medicine, 369 (15), 1389-1391 PMID: 24106932
As readers will have noted, obesity is an increasing problem in the Indian subcontinent, with urban prevalence (based on the lower definition of BMI 25) reaching rates comparable to the West.
In the overwhelmingly private healthcare system in India, ethical and evidence-based obesity management becomes an even bigger challenge than in a country like Canada, where we have publicly funded healthcare.
While, in a public system, we can point to the health benefits of modest weight loss and take a long-term approach based on the principles of chronic disease management, in a private health care system, where the customer is king, people will only pay for what they want – and that is to lose as much weight as quickly as possible.
As in Canada, it is hard convincing patients (and even most health professionals) that just losing 5% of your weight has significant health benefit. Indeed few patients would be willing to pay for a 10-15 lb weight loss – and keep paying for your help to keep them off.
Unless you can (at least claim to) offer 25 or 50% weight loss, it is unlikely that you will have many clients – there is simply no money in ethical obesity management. I have yet to find the patient who would pay me to simply help them stop gaining weight.
In the end, weight loss is really what everyone is after – I guess this is why surgeons still refer to bariatric surgery as “weight-loss surgery” – weight-loss sells!
For my colleagues in India, where they have to compete with an entirely unregulated and ruthless commercial weight-loss industry that promises a seemingly unlimited number of “slimming miracles”, practicing “evidence-based” obesity management is simply not a viable way to make a living.
This, perhaps is the greatest challenge to health professionals who wish to offer ethical weight management to their clients – they simply have no treatments that can match the weight-loss expectations of their potential clients.
Thus, I know that my talk this evening will disappoint most of my listeners, who may well be hoping that I can reveal the latest “magic solution” for weight-loss.
I truly wish I had a happier message for them.
New Delhi, India
During my current visit to New Delhi, it is hard to overlook the substantial increase in the prevalence of obesity in Indian men and women. While this may not be the phenotype that immediately comes to mind when thinking of India, there is no doubt that obesity prevalence is continuing to rise at an alarming rate.
Recent evidence for this comes from a study published by Chopra and colleagues from New Delhi, published in a recent issue of the European Journal of Clinical Nutrition.
In this systematic review of obesity in Indian girls and women were found to have consistently higher obesity rates than Indian boys or men.
Interestingly enough, abdominal obesity, sometimes referred to as ‘male-pattern’ obesity is in fact more common in Indian women than in men.
Not surprisingly, this increased rate of obesity is reflected in an increasing prevalence of type 2 diabetes that was reported to be as high as 14% in the 2001 National Urban Diabetes Survey.
Clustering of cardiovascular disease risk factors was further increased in post-menopausal women, not least due to a number of factors that may be of particular relevance in Indian women including sedentariness and overly caloric diets.
How exactly these increasing rates of obesity can be addressed remains anyones guess. While it is easy to see the proliferation of “slimming-centres” and “spas” at every corner, as in the West, these centres often provide little long-term help and of course generally do not cater to the folks, who would likely benefit the most.
Needless to say, the medical system in India, is as overwhelmed and insufficiently prepared to address obesity, as we are in the West.
Clearly a challenge if I ever saw one.
New Delhi, India
Regular readers of this blog will have noted previous entries on the “paradoxical” reverse epidemiology of obesity and cardiovascular mortality, where risk is apparently higher in underweight compared to normal weight, overweight or even mildly obese individuals (for e.g. of previous blog entries on this click here, here or here).
Now a new Danish study by Jawdat Abdull and colleagues published in the European Heart Journal that looks at pooled data from 5 large registries with over 21,500 consecutive high-risk patients with myocardial infarction or heart failure finds essentially the same story:
After a follow-up of 10.4 years, compared with normal weight individuals (BMI 18.5-24.9) all-cause mortality was higher in underweight (BMI < 18.5) but not in overweight (BMI 25.0-29.9) or class I obese (BMI 30-34.9) individuals. Only with class II obesity (BMI 35-39.9) and higher was there a significantly increased risk for myocardial infarction and increased death risk. This finding is very much in line with the mounting evidence that moderate overweight and mild obesity does not automatically translate into higher cardiovascular mortality in high-risk individuals with established heart disease. As argued before, given that increased weight is a well-established risk factor for high blood pressure, diabetes, and other risk factors for cardiovascular disease, the reasons for this rather consistent “paradoxical” relationship are not clear. Possible explanations include the idea that being underweight is a sign of general ill health and that thin people may be less able to cope with life-threatening illnesses like a heart attack at least compared to people with some extra “nutritional reserve”. Of course there are a couple of more sophisticated theories out there that to me appear highly speculative (which is why I will not mention them today). Nevertheless, in light of this “paradox”, we may have to look beyond reducing cardiovascular morbidity and mortality to justify aggressive treatments of overweight and class I obesity with established cardiovascular disease – perhaps the aim of obesity treatment in high-risk individuals should simply be to prevent further weight gain rather than to reduce it? I guess it would take intervention trials to find out – thankfully, these are already well underway. AMS