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OVERWEIGHT patients could be motivated to lose weight if their doctors broached the subject and set clear weight loss targets for them, according to Australian experts.
A study in the American Heart Journal has shown a physician diagnosis of overweight status was a significant predictor of attempted and successful weight loss.(1)
It showed diagnosing a patient as being overweight not only helped the patient recognise they were overweight but was also predictive of the patient wanting and attempting weight loss, and actually succeeding in losing weight in a 12-month period.
Yet, among the 907 patients with cardiovascular disease and central obesity in this study, only 62% reported that they had previously been informed by a physician that they were overweight.
Associate Professor Roger Allan, clinical cardiologist at Prince of Wales Hospital in Sydney, said doctors should address the issue of weight loss in all overweight patients and give them goals to strive for.
Professor Allan said there were barriers to doctors mentioning weight, which include trying to preserve a good relationship with the patient.
“To make people lose weight is such a challenge that to mention it means you have taken on the responsibility to try to do something about it and I suspect there may be that psychological barrier to talking about it.”
He said doctors should tell patients they want to see them again in 3 months’ time and “I want you to be three kilograms lighter”.
This type of encouragement should be ongoing and could include suggestions for long-term changes in their diet, including modification of carbohydrate intake and smaller portions, and encouraging daily walking, he said.
In the study, which used data from the US National Health and Nutrition Examination Survey (NHANES) 1999 to 2004, central obesity was defined as waist circumference of 102 cm or more in men and 88 cm or more in women. Success was defined as 5% or more weight loss in the preceding year.
The results showed 78% of respondents were aware of their overweight status and 80% wanted to weigh less.
Despite this awareness and desire, only 49% of centrally obese adults had attempted weight loss in the previous year.
People who had been informed by physicians of their overweight status were almost three times as likely to successfully lose weight.
Professor Ian Caterson, director of the Boden Institute of Obesity, Nutrition, Exercise and Eating Disorders at the University of Sydney, agreed there were several barriers to doctors mentioning weight with patients, despite the fact overweight and obesity were common.
“We feel uncomfortable, we feel we don’t really have much to offer … and it’s very difficult to do and takes time, and there is also the commercial imperative because you are bit worried about upsetting somebody and having them go down the road,” he said.
“We happily write prescriptions for antihypertensives and oral hypoglycaemics and statins, and that’s easy, but we have got to get better at lifestyle management,” Professor Caterson said.
Dr Andrew Binns, a NSW GP with an interest in lifestyle medicine, said the emphasis should be on an overall lifestyle approach to keep the heart healthy, whether the patient was overweight or not.
“Even if someone is unable to lose weight, which is common among [people with type 2 diabetes], then improving diet and increasing activity levels can have metabolic benefits and [bring about] CVD risk reduction without weight loss,” he said.
A study published in the New England Journal of Medicine last week showed patients were more likely to stick to a diet and maintain weight loss if their diet included a modest increase in protein content and a modest reduction in the glycaemic index.(2)
1. Am Heart J 2010; 160: 934-942.
2. N Engl J Med 2010; 363: 2102-2113.
Posted 29 November 2010
Guy, with due respect, you have a lot to learn about science. A hypothesis needs to testable not self-fulfilling ie “likely to be true by definition”. This is the sort of thing that the general public does. Only a small percentage of morbidly obese can replicate your experience at weight loss maintenance in the long-term, and the reasons are NOT known; speculate as you might – it contributes nothing to helping these individuals. I know more about the ANZDATA registry where *every* patient on dialysis and receiving a transplant *is* registered by the clinicians looking after them; now that is a proper registry. The surgical registries you mention have patients registered by, I presume, the clinicians who register both successes and failures using the same prostheses and/or same surgical techniques. On the internet, anonymous self-reporting without verification has to be suspect. And even if we were to accept everything in the weight loss registry as true, we can’t assume it’s general applicability. Your Warren Buffet analogy misses the point: to decide whether something works or not it needs to be subjected to trial not conjecture. Then comes the issue of general applicability. Lifestyle modification has been subjected to extensive trial and has come up wanting in the LONG-TERM in the clinic. If it was an anti-hypertensive you wouldn’t use for your patients. Your comments about knowledge, skill and persistence are conjecture, but beg the question why there are fat doctors and dieticians both of whom have the knowledge and skill, and have the persistence to achieve highly in their careers, yet fail to lose weight.
Well I certainly maintained all the weight loss throughout the 6 years of medical school and well into residency.
Why is it pseudoscience to say that people who are overweight are not following an effective weight loss regimen? I would have said that it was likely to be true by definition.
Why does voluntary self reporting invalidate a registry. Do you imagine that the Australian Joint Replacement Registry and the Australian Breast Implant Registry are compulsory? They are not. And yet their results are taken very seriously in regulatory medicine.
To say that the US National Weight Control Registry does not track all comers and is therefore not representative misses the point of the registry, which is to identify successful weight loss strategies.
One may as well argue that Warren Buffet’s investment strategies do not work because his success has not been replicated by everyone in the world. Investment takes persistence and a certain amount of knowledge and skill and why should it be any different with weight loss?
Guy’s personal experience is very uncommon (although it does occur), and he had yet to tell us how long he has maintained the 20kg he is trumpeting. And he fails to appreciate why his (most-likely) experienced GP was in fact dumbfounded. Quite likely, as a medical student, he was young, and able to shed weight more easily; it is a lot harder as one gets older.
His comments about selection bias are pseudo-science, in effect, making up untestable self-fulfilling prophesies/hypotheses: if you’re thin you must be following a diet, and if you’re fat you’re not.
The research shows that that nearly everyone can lose weight in the short-term. It’s the long-term that’s the issue. The Weight Control Registry is NOT a true registry in any way shape or form. The so-called registrants are self-reported; so the truth of what they are reporting is taken on faith. It does not track “all-comers” on a weight-loss programme; so that the true failure rate of that programme would be known. In short it has been a clever way for someone to generate papers without doing any real work! In any case, the success of these lucky 5000 can not be extrapolated to the millions of the morbidly obese who are destined to fail lifestyle modification.
Dean Ornish’s study has little to offer as well – 5kg weight loss fall way short of what most patients need, and what they can achieve with lap-bands; is there selections bias in this study? (Was it actually a trial?)
I think that there is likely to be selection bias here. The fact that many normal weight people are constantly undertaking diets suggests that diets can in fact work if you follow them. I would suspect that the more centrally obese somebody is the greater the selection bias is for not following the program.
However, this is not absolute as we know that in the cohort of the US National Weight Control Registry there are over 5000 individuals who have lost over 30kg on average and kept it off for an average of more than 5 years. The strategies they employed are well documented, few in number and highly predictable.
See http://www.nwcr.ws/Research/default.htm
There are thus no real hidden secrets of weight loss. The art of weight loss lies in applying these already well documented strategies. Marketing expert Todd Beeler, in his book The Six Hidden Secrets of Motivation, lists “reason why” as the number one motivation secret. People need a good reason to do things, including losing weight.
US cardiologist Dean Ornish, who is one of the few people ever to publish a prospective trial where subjects maintained a 5kg weight loss at 5 years, states that fear of dying is not a sustainable motivator, whereas joy of living is. People thus need to focus on the positive benefits of weight loss. Another important motivation secret is to believe that the goal weight is achievable. When I was a medical student, my GP told me to lose 20kg. When I returned a few months later and told him that I had done it he was dumbfounded. I could not understand this as nobody had bothered to tell me that weight loss was supposed to be really difficult. If they had then maybe I would not have attempted it.
I found it has been very helpful to know my GP expects me to achieve an ideal weight of 65 kg.
At the time he told me this, it meant I had to lose 10 kg — but he let me do the maths.
Now, a year or so later as I approach that goal, having changed my eating habits and exercise patterns and lifestyle choices, I feel so very good about myself.
I believe that after many years of trying to shed those few kilos I would say it was my GP’s objectively stated expectation that I could lose the weight that motivated me the most.
Hope that is helpful to other doctors out there.
Rick is right, which is why I take a similar approach – ie, try to get in early when they are less than 12 kg overweight and tell them, “look, this is do-able, but only if you address it now – if you get much higher, then you will find it almost impossible to reduce it, so do it now!”
Those in whom the risks of not doing outweight the risks of doing, and who are really obese, I refer for lap banding if they have the cover….. realistically/sadly it is their only chance, as it is seldom one is dealing with a potential ‘Weight Watcher of the Year’.
It is about time that leading medical bodies recognised and enunciated the truth: there is no obesity unit in the world that can demonstrate sustained long-term weight loss in more than about 10% of obese patients. The diet and exercise approach to LONG-TERM weight loss is a myth for most patients. The counter-regulatory responses to weight loss make failure inevitable for most, and the reasons are not well understood. Otherwise, there would be no fat doctors!
I suspect that most experienced doctors already know this, and this is the reason that they don’t waste time offering useless advice.
At best, diet (not dieting) and exercise may prevent weight gain.
If one looks up UpToDate OnLine for the latest recommendations on treating obesity, it is disappointing: at best grade II – ie “take-it-or-leave-it” advice because of the lack of good evidence for treatment.
I tell patients, “For God’s sake don’t put any more weight on, because it will be a struggle to get it off and keep it off.”, and I tell them not to expect miracles from the traditional approaches – as if most didn’t already know …
I am appalled at a doctor suggesting the physician should say “I want you to be three kilograms lighter”. This attitude in doctors – that you are supposed to do it because I say so – and to make them happy, is a large reason patients will not do anything this physician suggests. That is so disrespectful.
It has also frustrated me for a long time that the common approach to measurement of needing weight loss is the circumference of the waist, with no corresponding height measurement e.g. if my waist measurement, at my height of 175cms were the same as that of my daughter in law who barely tops 152cms, there would be something very seriously wrong with at least one of us.
Doesn’t this just show that researchers don’t think?!
Let’s look at this again – from the point of view of rationality.
I tried telling it like it is as a GP trainee…
I wrote Px that said simply “Take less food and more exercise daily”. Not many people liked that truth very much.
Now I am older, perhaps times have changed, cos I still tell it like it is.
People can take it or leave it.