White Coat Underground

Just get un-fat already!

It’s hard to avoid news about the “obesity epidemic”. Depending on who you talk to, obesity may be the number one killer of Americans or completely irrelevant to health. Alternative med boosters love to focus on obesity and other supposedly behavior-related illness. They use this to simultaneously blame the patient for their own ill-health, blame society for enabling them, and blame real doctors for not fixing it right.

The truth is that obesity is a real threat to health. The causes are protean. Societal problems, individual genetics, and politics can all contribute to obesity, as can personal choice and behavior.

In medicine we have a concept of “compliance”; when a patient fails to follow our recommendations, we often label them as “non-compliant”. This serves a few purposes: it communicates a certain impression about the patient (one that may or may not be accurate) and it helps immunize us against legal shenanigans. The idea is that if you clearly document that you tried to help the patient and that through no fault of your own they didn’t follow through, you shouldn’t be held responsible for a bad outcome.

There has been for several years a trend to use the term “non-adherence” rather than “non-compliance”. It’s thought that this has fewer paternalistic connotations than “compliance”, although I’m not sure simply changing the word can do this. Also, I’m not so sure that we should be so quick to absolve ourselves as doctors of a more active role in our patients’ health. While it’s certainly true that we can’t make people do what we think they should, we should make sure we understand what barriers they have to compliance. This is especially true of addictive behaviors.

When one of my residents tells me a patient is non-compliant (or “non-adherent”–whatever) my first question is always, “why?” Did we fail to communicate well? Did we give bad advice? Is the patient depressed? If we understand why the patient didn’t follow our advice, we’ve got something to work with. If we simply say “non-compliant” all we’ve done is immunize ourselves from a feeling of guilt. We haven’t done a thing for the patient.

Obesity is a tough problem. For most people, simply telling them to eat less and exercise more will not work. But it’s especially important to know what barriers patients face independent of their own mental health.

Affordable fresh foods are very difficult to find in some areas, especially inner cities. If you don’t have a car, you can’t schlepp out to the burbs to pick up broccoli. And if you’re raising kids and trying to eke out a living, anything that saves time is more likely to happen. If you’re living on a Bridge Card and half a minimum wage job, and you’re trying to keep the heat on and the kids tummies full, you’re going to be more likely to butter up some Wonder Bread and open a can of Chef Boyardee then whip up a fresh salad, chicken breast, and pasta primavera. And if you live in a lousy neighborhood, even if you find someone to watch the kids, you’re probably not going out for a run.

And you don’t have to be poor and living in the inner city to have problems eating right and exercising. There are plenty of other people working hard and/or raising families who simply feel unable to find the time to eat well, sleep right, and exercise. We haven’t built a society around these behaviors and we don’t encourage them.

While excuses are no substitute for action, you can’t take care of people properly if you don’t try to understand what makes them tick. I can tell someone over and over to lose weight and exercise more, but if they can’t pull it off, I can’t wash my hands of them and watch them rot. It’s easy to lose sight of the struggles of others, especially the subtle, silent ones. While I’m counseling them to exercise, they may be worried about how the gas company will get paid. I have to treat the person in front of me, not the patient I want them to be.

Comments

  1. #1 Pascale
    January 6, 2010

    There is also the bit about how hard it is to lose weight!
    When I was a student, I couldn’t understand why these patients didn’t just do it; now the I’m pushing 50, I get it!

  2. #2 Cerus
    January 6, 2010

    Thank you for writing on this issue. One of my term papers analyzed this very issue.

    The interaction between obesity and social/behavioral constraints is crucial for effectively helping curb the obesity problem. Of interest to me is: how/ can public health successfully address obesity without addressing social and behavioral factors? And, would they, even if it is necessary for greater success?

  3. #3 CanadianChick
    January 6, 2010

    not to mention all the psychological issues that might be part of the weight problem. I KNOW what I need to do to eat properly and exercise, AND I can afford to do it, so what is stopping me? It’s taken more than a year of cognitive behavioural therapy to get me to the point where I’m starting to see WHY I’m not doing what the rational part of me KNOWS how to do and why to do it!

  4. #4 Bill
    January 6, 2010

    At least you say something to your patients.

    My family doctor’s never said anything to me, even though I am at least 30 kilos overweight.

  5. #5 Comrade PhysioProf
    January 6, 2010

    Wonderful analysis, holmes! The fact of the matter is that a treatment that would be 100% effective if only patients “complied” is totally fucking useless and not a treatment at all if very, very few patients *do* comply. Continuing to push that treatment and blame the non-compliant patients for the failure of the cure is gross dereliction of duty. It is a problem with the cure when the vast majority of patients do not comply.

    One of your former Denialism colleagues really had his head up his ass on this one, but maybe now that he’s been working with actual patients longer, he’s realized the error of his ways.

  6. #6 anonymous
    January 6, 2010

    I find generally people in USA are careless and lazy when it comes to fresh food. They also don’t get enough training in cooking healthy fresh meal at home. I cook everyday fresh meal for my family at morning 7 am. It takes some efforts but then no one eats junk food. When I tell them its not as hard as they think, People just say wow!

  7. #7 PalMD
    January 6, 2010

    Im considering editing anon’s handle to “clueless”.

  8. #8 Stella
    January 6, 2010

    My doctor mutters a few noncommittal phrases and shoos me out the door. He wouldn’t spend the time giving me advice I can comply to, or adhere to, if I asked him. I’m on my own with weight management, and that’s how it is.

    I’d love to meet some of these MD’s who take a personal interest in their patients’ weight… and their patients’ health in general. I would especially love to have a PCP who follows “I don’t know” with “…but I can find out.” Sadly, in my experience the real medical world doesn’t reflect the level of interaction described in this post and other articles I’ve read. I laugh when an article recommends that I ask my physician. What do they think he’ll say?

  9. #9 PalMD
    January 6, 2010

    Despite what the experts say, it’s very difficult to create actionable advice for patients regarding weight management.

  10. #10 Zuska
    January 6, 2010

    Everytime I see my PCP she keeps asking me about my exercise regimen. One of the last times I saw her and I told her what I was doing (which was pathetically minimal) she praised me and encouraged me to up the time I was spending on one particular exercise from 20 min 2xweek to 30 min and try for 3x week. I did do that. Just her little intervention made a difference. I was doing great till my knee starting giving me problems and I couldn’t go to the gym at all anymore. Damn body keeps giving out on me.

    But regarding the fresh food in the cities – you are right on target there, Pal. One of the initiatives of the Pennsylvania Horticulture Society is to try and get more kids in the city, more city folks in general, growing small veggie gardens on vacant lots – reclaiming land that would be ugly and garbage strewn otherwise, and generating healthy food for those who have little access to it otherwise. And teaching young kids business skills. There just aren’t enough grocery stores in the city, and the stores there are, don’t have a lot of great fresh produce. If you can even afford what’s there.

  11. #11 skeptifem
    January 7, 2010

    I know a lot of overweight/obese people who are dismissed by doctors because of their weight. Sometimes it was related, sometimes the illness had nothing to do with weight, sometimes the weight gain was a symptom of the problem not poor self control, etc. But most of the time they just got told to lose weight. Fat acceptance websites have tons of people who have experienced that, and it has been an issue on a lot of episodes of ‘mystery diagnosis’. Some of the people who are overweight have eating disorders (COE, BED, bulimia) but do not get referred for psychological help because fat is treated like a moral issue.

    Then there are all the normal range folks like me who didn’t get asked about their diet at check ups when it was extremely poor.

  12. #12 Uncle Glenny
    January 7, 2010

    Pal:

    How much time do you get for an office visit? My prior PCP worked out of a hospital and visit time shrunk to 15 minutes around 1999. I’ve heard it’s less now (for various reasons I don’t have a PCP and haven’t seen a doctor outside an emergency setting since 2002).

    Zuska:

    Is lead in the soil an issue?

  13. #13 Kristen
    January 7, 2010

    I am sure it is very frustrating for doctors when they feel unable to help because of the patient’s circumstances. We, as a society need to find a better way to work on this problem.

    For those who are physicians, don’t underestimate the effect of your encouragement and advice, you never know when it will hit home. Perhaps losing weight need not even be mentioned, just concentrate on lifestyle modification and the health will follow.

    For those unable to improve their diet and unable to exercise, I don’t have an answer. So much needs to improve that has nothing to do with their habits, society needs to change.

  14. #14 Isis the Scientist
    January 7, 2010

    Despite what the experts say, it’s very difficult to create actionable advice for patients regarding weight management.

    I think what you mean is, within the boundaries of the current health care system, it’s very difficult.

  15. #15 Dianne
    January 7, 2010

    If one patient is non-compliant, that’s probably an issue with the patient (not necessarily a fault of the patient, but a problem specific to that patient, whether it be lack of money for medication, disagreement with the advice or simply an indifference on the individual’s part to his/her own health.) If essentially no patient can comply with a particular piece of advice then the problem is with the advice. So, the advice “just get un-fat” is not good advice because, even if it could lead to better health if followed*, it’s useless if it can’t be followed.

    Advising people to lose weight per se is probably a lost cause. There has been some success, both in durable weight loss and improved health, using surgical maneuvers for severe/morbid obesity, but the technique is too invasive and dangerous to be of much use for mild obesity/overweight patients.

    Dieting, per se, is asking someone to voluntarily starve themselves in the midst of plenty. Not going to happen. Not often, not permanently. Not even for a person with the wealth and time to do it. Stopping further weight gain and improving fitness is a more reasonable goal…if the patient can afford the time and money needed to buy and prepare the right foods, has enough time to exercise, etc. And sleep: there is some evidence that people who don’t get enough sleep gain weight. (May be confounded by sleep apnea, but interesting nonetheless. Maybe part of the lifestyle problem of modern US-Americans is the “work ethic” that insists that we all work 60+ hours/week.) But those are pretty major caveats: as already pointed out, many people simply don’t have the time and money to make the lifestyle changes needed.

    So, what to do? We can’t prescribe one social revolution for preventative care. As an anecdote to illustrate the problem, when I was a resident I saw a patient with a chief complaint of wanting to lose weight. I talked to her about her eating and exercise habits and generally how her day went and discovered that she was working about 110 hours/week (working 3 jobs). Oddly enough, with that schedule she didn’t have time to eat right or exercise (not to mention the lack of energy to exercise.) I’m afraid I just made the usual BS recommendations, but what I wanted to say was,”Quit two of your jobs and organize a union and demand a living wage in your third.” But that was probably just as far out of her reach as preparing organic vegan meals every day and hiring a personal trainer. I don’t know. There just doesn’t seem to be a good solution.

    *I have some concerns about the concept that weight loss=better health, but they’re probably a bit of a derailment so I’ll only get into it if Pal as the thread author agrees.

  16. #16 catgirl
    January 7, 2010

    Losing weight is very difficult, and common sense advice doesn’t always work. Patients may try to be compliant, but it’s very difficult, and not just because of the excuses you listed. I think the benefits of exercise for eight loss have been exaggerated. I’ve tried exercising many times over the years, and it has never helped me. For some reason, I keep trying anyway, hoping it will work even though it had failed so many times. The problem isn’t about commitment. Most recently, I followed a good exercise program consistently for 15 months. (I stopped when I developed gallstones and had to have surgery). I didn’t lose any weight, and I actually gained more. On top of that, I didn’t feel any healthier or more energetic. My resting heart rate never improved, and I never saw any improvement in my ability to exercise (I couldn’t do it more intensely or for a longer period of time). I’ve often wondered if there’s something wrong with me that makes exercise basically useless. I’ve tried explaining this to several doctors, but either they assume I’m lying about how much I’ve exercised, or my results are typical so they’re not surprised.

  17. #17 Kathryn
    January 7, 2010

    Isis, I think Pal meant exactly what he said. The health care system has very little to do with why I have trouble complying. My neighborhood in the city has no sidewalks and narrow roads. Not good for walking. I don’t have a car but I could walk about two miles along a very busy street to a park that has a nice paved walking path. Which would be during the dark hours because I work 7a-7p. That’s if I can find someone to stay with the kids for free because i can’t pay them on my $27, 000.00/yr. Considering the job hours and the income, not much time left for cooking fresh food each night. Did I mention that I have another job (the both together come to the $27,000)? The lack of a car makes shopping tough. Ever tried to schlep sacks of groceries on a bus? Pretty much have to do this every couple of days if I want to eat fresh stuff. So yeah, I could make better choices but I’m just too damned tired at the end of the day. And the “current health care system” has nothing to do with it.

  18. #18 Constance Reader
    January 7, 2010

    Just to reinforce #16. I also followed a long term diet and exercise program, including a personal trainer. My flesh firmed up but strength and stamina plateaued at six weeks and did not improve as the months passed. I gained weight (so much that my PCP was concerned) because I was constantly eating, a hunger so persistent that it was distracting me from normal activities. Instead of gaining energy I was sleeping 12-13 hours per day. While my flesh ceased to shimmy, cellulite became more visually apparent as the muscle underneath it became more firm. I’m so lumpy now that I won’t wear shorts or a swimsuit in public. And to top it all off, my upper legs were numb, which my PCP attributed to femoral nerve compression.

    So please keep in mind that among the many factors for obesity, there is one possible factor that many physicians seem unwilling to accept (and that I have finally had to accept in response to the empirical evidence of 2009’s great efforts, but am having emotional difficulty coping with): some of us are genetically programmed NOT to respond positively to diet and exercise.

    Lastly, I’d like to point out that low calorie and low fat often equals processed. For example, margarines and similar spreads may be lower in calories and fat, but they are also not real food. I have a friend who is very happy with the 100+ pounds she has lost in recent years, but I am concerned that she achieved and maintains that weight loss by a diet that is almost exclusively highly processed, low-cal low-fat food products.

  19. #19 Dianne
    January 7, 2010

    @18: I strongly suspect that losing weight with diet and exercise is a bit like trying to lower your blood pressure with a low sodium diet: it works for a few people but not by any means for everyone. Unforunately, we don’t have the drug or drugs that would keep obesity under control. It’s being sought, but really we’re trying to fight millions of years of evolution all of which have selected the animals (including people) who are most likely to be able to maintain weight under conditions of starvation. We aren’t really evolved for plenty.

  20. #20 Calli Arcale
    January 7, 2010

    Define “real food”. In our society, “cheap food” means processed, because what makes it cheap is the fact that it keeps well and making food keep well requires processing. (Food processing is one of the ancient techniques which, along with agriculture, allowed us to build civilizations.) But it’s still real. Bread’s pretty real, and pretty heavily processed, even if made by stone age techniques.

    But not “real food”? What does that even mean? The main problem with certain processed foods is that the processing (cooking, grinding, pickling, etc) breaks down various structures inside it, making it much easier to extract nutrients from it. This was a great thing 5,000 years ago; suddenly, people could eat stuff their ancestors couldn’t, and survive and thrive on much less volume of food. Today, at least in wealthy countries, it leads to obesity, because food is so plentiful that processing it only makes the caloric situation worse.

    (Note: this is not a new problem. Obesity has been a problem in every wealthy society, and for exactly the same reasons.)

    BTW, margarine is not really a low-fat food. People have this impression it is, but it’s not. Even the low-fat varieties aren’t really low-fat. They’re just not quite so high-fat as the regular kind. It’s sort of like eating low-fat cream cheese — the result is still mostly fat. It’s a bit lower in saturated fats than butter is, but this is still just a matter of degree. Like calling Saturn a small planet because it’s smaller than Jupiter.

  21. #21 History Punk
    January 7, 2010

    Not to mention that exercising in some areas in the United States cares a substantial risk of being a victim of a mugging, shooting, or rape. In Baltimore City, I’ve seen well-meaning but utterly clueless yuppies tell ghetto kids that they need to play outdoors more. I laughed my ass when my friend from Bosnia told the lady that driving through the East Baltimore ghetto was often enough to trigger memories and nightmares about his time under siege in Sarajevo.

  22. #22 DuWayne
    January 7, 2010

    I think it is very important to understand that for a lot of people obesity is as much an addiction as cigarettes or alcohol can be. It is very sad that there are a lot of people in addiction or general psych who do not consider behavioral addiction addiction at all, but it is. It is simply not as simple as telling someone to eat right and exercise – even if those are possible in the first place. That is like telling someone to quit smoking or quit drinking. It is possible, but it is not easy – nor is it something that is reasonable to moralize.

    That is not to say that all obesity is due to addiction, just that a whole lot of it is.

  23. #23 Lyn
    January 7, 2010

    To #18: you have a friend who has lost 100 pounds, and you’re “concerned” that she did it eating processed foods? Any risk from eating processed foods – whatever that means – would be far outweighed by her reduction in risk from losing the weight.

  24. #24 Lyn
    January 7, 2010

    Just to follow up: it is possible to lose weight (or at least arrest weight gain) without exercising and without eating mostly fresh food (just as it’s possible to gain weight eating lots of healthy fresh food, if you don’t control the intake). Obviously, it’s much easier to lose weight if you can exercise and get better quality food, but that’s not possible for some folks, as has been documented above. So what if doctors tried to focus on getting patients to change just ONE thing, in the hopes of at least preventing more gain. For instance, the doctor could ask whether the patient (and family) drinks any regular soda or fruit juice. If the answer is yes, the doctor could say, “Just make this one change: don’t drink any of your calories” (perhaps skim milk would be an exception). Ideally, the patient would switch to water, but if s/he has a real soda habit, diet drinks would still be better. Or, the doctor could just ask, “Can you think of ONE thing you could do to work on this? — perhaps giving examples such as ordering smaller portions or forgoing fries, or not eating in front of the TV after dinner, or walking to the park with your kids on the weekend, or even going bowling (I would guess they’d be more likely to see results with dietary changes than with adding small amounts of exercise, but any exercise can have a positive psychological effect). More could be done from there, once the new habit is ingrained. Otherwise the task can just seem overwhelming and people won’t even start.

  25. #25 Dianne
    January 7, 2010

    Any risk from eating processed foods – whatever that means – would be far outweighed by her reduction in risk from losing the weight.

    Do we know that? First question: There are known risks to being overweight but does weight loss reverse those risks? Does the method of weight loss matter? There are a few smallish studies on either side of the question. The second is are processed foods detrimental to health in any way? Probably an unanswerable question given that there are many different types of processed foods, but again, what is the evidence of risk?

  26. #26 OleanderTea
    January 7, 2010

    Pal, I totally agree with you. As a society, we’re far too fat. But more worryingly, we eat far too much crap. I try to eat by the “if my great-grandmother wouldn’t have recognized it as food, don’t eat it” guideline. It works pretty well. I also spend way less time in the grocery store now that I’m shopping on the margins.

    However, can I request that docs help out the patients by treating obesity as a medical problem, and not as some kind of moral failing?

    On a related note, it would also help if docs would stop assuming that every one of a patient’s medical problems are always and solely because of the patient’s weight. True story: I saw a new doc about chronic migraines. Doc took a sketchy H&P, then said that “obese patients have a higher rate of chronic migraine” and suggested that I needed to lose weight to help treat the migraines.

    I replied that I was of normal weight when the migraines became “chronic”. Then I pointed out that the main side effect of most migraine preventatives is weight gain. And I wondered aloud if the stats confuse correlation with causation.

    Doc looked at me like I’d grown a second head.

    It really is annoying to be doing all the “right” things and still be treated like I’m shoveling Velveeta and Twinkies into my mouth.

    [/rant]

    But, again…I totally agree that Americans eat far too much crap food.

  27. #27 OleanderTea
    January 7, 2010

    Most insurance excludes coverage for ANY weight-loss treatments; many are now not covering bariatric surgery for the obese, even those with with other health problems.

    The message patients get when they are told that their visit isn’t covered for “weight loss” is that weight is a cosmetic issue, not a medical one. Which would be wrong.

    Think about it: insurance will pay for blood-pressure medication, diabetes treatment, stroke treatment and rehab, heart surgery, knee and back surgeries. But not for a few visits to the doc to discuss weight control.

    Bad, bad message.

  28. #28 PalMD
    January 7, 2010

    Slightly OT, but while I can recommend OleanderTea as a commenter, I cannot recommend it as a beverage. Oleander is rather poisonous.

  29. #29 Vicki
    January 7, 2010

    I exercise regularly, and my weight has been stable for a long time, with two exceptions, even when I tried changing what I ate.

    Exception the first: I was being treated with prednisone. I lost a dozen pounds in about as many days, without trying. My partner pointed out that I was also getting about four hours of sleep a night. The steroid was acting as a stimulant. Go figure. (This is unusual enough that my doctor recommended I monitor my weight for a couple of months, to be sure I hadn’t developed some other medical condition: unexplained weight loss can be a sign of serious problems.)

    Exception the second: I had my gall bladder removed a couple of years ago, and ate almost nothing for the first week or two after the surgery.

    I gather I’m unusual in that I didn’t regain the weight from either of those. But even if that were the usual outcome of steroid use or having organs removed, I wouldn’t recommend it, and I wouldn’t call someone “non-compliant” for telling their doctor that they thought these were bad ideas.

    What the exercise does get me is strength, self-confidence, and maybe even healthy good blood pressure (the good blood pressure numbers may be coincidental). It’s worth it. And a culture, medical and otherwise, that equates exercise with weight loss doesn’t help, because it means people who take up exercise and don’t lose weight are likely to quit, rather than noticing the actual health benefits of walking, weight lifting, swimming, etc.

  30. #30 catgirl
    January 7, 2010

    Any risk from eating processed foods – whatever that means – would be far outweighed by her reduction in risk from losing the weight.

    This is not necessarily true. While being overweight certainly has plenty of health risks, I don’t like this idea that weight=health, or that weight is a bigger health problem than anything else. I don’t know about this person’s personal diet, but if he or she ate low calorie foods that aren’t nutritious, that could certainly cause a problem. Many diet programs lack certain foods, and “low calorie” doesn’t always mean “healthy”. Also, neither of us knows the starting weight of the friend who lost 100 pounds. If he or she was only moderately overweight to begin with, they could be at risk for anorexia. Of course we know very little about this person, but assuming that losing weight means they don’t have to worry about anything else is just false.

  31. #31 catgirl
    January 7, 2010

    And a culture, medical and otherwise, that equates exercise with weight loss doesn’t help, because it means people who take up exercise and don’t lose weight are likely to quit, rather than noticing the actual health benefits of walking, weight lifting, swimming, etc.

    The problem is that I haven’t actually noticed any health benefits from exercising. Honestly, I’ve never expected to lose weight from exercising. But I always expected to feel healthier, and I’ve been let down every time. I expected to feel stronger, have more endurance, or just have more energy throughout the day. It has never done any of those things for me. I keep doing it anyway, although feel a bit foolish for continuing to do the same thing and expecting a different result. I’ve told multiple doctors about this, but they just tell me I need to keep doing it. If nothing happens after 15 months, then how long should I wait to see any change?

  32. #32 Kim
    January 7, 2010

    I’ve lost about 50lb, with occasional bursts of effort but often more by accident, over the last 3-4 years. I expect I’ll probably lose another 30lb or so over the next few years. I’m sure I could lose more faster with sustained effort, but I have some limitations I won’t get into.

    One very real problem, IMO, is that doctors as much as everyone else buy into the concept of the quick fix. I once memorably had a doctor shout at me “well, whatever you’re doing, it’s not working!”…never mind I’d lost about 25lb since our first appointment 2ish years previous and was now active enough that “programmed rest day” was a meaningful concept. The more usual run-of-the-mill disbelief I get from doctors and office staff if I’m not actively in a run of losing weight quickly is much less dramatic but still far from appropriate, IMO. For someone who *is* working hard for a 1-3lb/month loss and feeling discouraged about it — which is not at all uncommon! — that sort of frankly shitty feedback from a physician could certainly send her back to the Ben & Jerry’s (and a new internist).

  33. #33 stripey_cat
    January 7, 2010

    My weight has been pretty stable since I reached my full skeletal growth. I’m moderately overweight for my height, which is probably partly due to a very robust skeleton. Exercise shifts more of the weight into muscle, less exercise means more fat, but the weight stays roughly the same. Calorific restrictions make me faint and hypothermic, but I don’t lose weight! (Seriously, I was eating less than 500 calories a day for about a month when I had a chest infection back in university: before I finally got antibiotics I couldn’t stand without assistance, and my muscles had vanished, but I had only lost about two pounds and my skirts wouldn’t close at the waist for the new fat deposits.)

    I’ve finally resigned myself to always being stocky (built like a brick sh*t-house, in my brother’s elegant phrasing), and am trying to keep the muscle-to-fat ratio reasonably good. Of course, muscle needs more calories to support than flab does. I find it very annoying when I’m told to try portion control/calorie counting, and I try to explain that all that’ll happen is I’ll lose muscle tone and faint if I try to exercise harder. Even though my medical record is full of unexplained fainting and dizziness which stopped roughly when I stopped trying to keep my weight low.

  34. #34 becca
    January 7, 2010

    “When I was a student, I couldn’t understand why these patients didn’t just do it; now the I’m pushing 50, I get it!” I’d like to feel smug for never being blind about that, but it’s all what you’ve been exposed to. Growing up as a fat kid and watching a relative go for 10 years with undiagnosed hypothyroidism is an incredible inoculation against the particularly ugly, unscientific, and typically youthful, conceit that loosing weight is easy.

    Kathryn- As part of the healthcare system it is possible for people to get their gym memberships paid for (at gyms that have daycare), so if they can’t get to a sidewalk at least they can get to a treadmill (granted, we may have chronic vitamin d deficiencies that make that a poor choice, but on the other hand at least the -10 cold snaps aren’t as much of a problem). As part of the healthcare system, it is at least imaginable to subsidize fresh fruits and veggies. It might even be a good investment in preventative medicine. The societal problems that contribute to weight loss are broader than the healthcare system, but the healthcare system is far from ideal.

  35. #35 OleanderTea
    January 7, 2010

    “Slightly OT, but while I can recommend OleanderTea as a commenter, I cannot recommend it as a beverage. Oleander is rather poisonous.”

    Many thanks, Pal. I’m a southerner and know well the toxicity of oleander — in fact, my nic is from its use as a poison (both in fact and in fiction); tea was a civilized way to off someone. Weirdly, I’ve read of some natural-healing nutters using oleander tea or soup as a treatment for cancer and AIDS. I certainly wouldn’t recommend it.

    [/hijack]

  36. #36 Professor in Training
    January 7, 2010

    I think the benefits of exercise for eight loss have been exaggerated. I’ve tried exercising many times over the years, and it has never helped me. For some reason, I keep trying anyway, hoping it will work even though it had failed so many times. The problem isn’t about commitment.

    I didn’t lose any weight, and I actually gained more. On top of that, I didn’t feel any healthier or more energetic. My resting heart rate never improved, and I never saw any improvement in my ability to exercise (I couldn’t do it more intensely or for a longer period of time).

    It’s for these exact reasons that people who are new to structured physical activity or are trying to lose weight should consult with an accredited exercise physiologist. Very few gym instructors and almost no medical doctors have the specialized training required to prescribe, monitor and adjust exercise programs for individuals.

    The problem is that I haven’t actually noticed any health benefits from exercising.

    Depends on what you mean by “health benefits.” If you’re referring to positive effects on cardiovascular health, it will first depend on whether you had, for example, hypertension, hypercholesterolemia, a high resting heart rate, etc. In general, if you didn’t see a positive effect in any of these after an extended period of time, you either (1) haven’t been doing the right kinds of exercises, (2) weren’t doing them at a high enough intensity, (3) weren’t doing them correctly, or (4) weren’t exercising often or long enough. If all of these markers were normal or close to normal to begin with you won’t see much change unless you get into a very rigorous training program and continue with it for a longer period of time.

    For most people, losing weight is as simple as reducing caloric intake and increasing energy expenditure. Consult with your physician, an accredited exercise physiologist AND a registered dietician for the safest and most effective way to achieve weight loss.

  37. #37 Professor in Training
    January 7, 2010

    I almost forgot to mention that exercise does far more than just reduce blood pressure and resting heart rate. There are many, many changes at the cellular level that protect against ischemia/reperfusion injury and this occurs independently of any change in systemic, clinical measures. Just because you can’t “see” any health benefits of exercise, doesn’t mean it’s not doing good things for you.

  38. #38 DLC
    January 8, 2010

    I hate to be a fly in the ointment, but :
    the reason to prepare your own food from scratch isn’t because fresh food is magically healthier than canned or frozen food, but because when you make it you can control the ingredients and portions. It is entirely possible to live on canned spaghetti and meatballs, or even Army MREs.
    It’s the balance that matters. use more than you take in and (barring unknowns) you’ll lose weight. lose weight and you’ll be healthier.

  39. #39 Dianne
    January 8, 2010

    It is entirely possible to live on canned spaghetti and meatballs, or even Army MREs.

    Technically true, but your will to live…

  40. #40 catgirl
    January 8, 2010

    if you didn’t see a positive effect in any of these after an extended period of time, you either (1) haven’t been doing the right kinds of exercises, (2) weren’t doing them at a high enough intensity, (3) weren’t doing them correctly, or (4) weren’t exercising often or long enough.

    Don’t you think I’ve already considered these possibilities?

    1) 30-60 minutes of cardio and 15 minutes of weight training 3 times a week. Is that the wrong kind of exercise?

    2) I use a heart rate monitor and stay in the correct “zone” for cardio health, as much as I can. I’ve tried going higher than that, but it’s just not sustainable and makes me feel exhausted for the rest of the day.

    3)I don’t really know how I could use a treadmill, bicycle, or eliptical machine incorrectly.

    4)3 times a week (minimum) for 15 months, and still nothing. Should it take years to notice any effect at all?

    I think you’re focusing way too much on the weight loss thing, which I didn’t really expect anyway. Everyone I know, including doctors, insists that losing weight will lower resting heart rate and increase energy and stamina throughout the day. On top of that, after several months of exercise, shouldn’t I get better at it? Shouldn’t I be able to do it faster or for a longer time? Shouldn’t it become easier to exercise at the same level I started at so I would have to increase intensity to get the same workout? Shouldn’t I feel moderately stronger in some way?

  41. #41 gaiainc
    January 8, 2010

    I read this at the beginning of my clinic yesterday. Most of the patients that I saw (including me) could stand to be skinnier. However, what they could probably stand to be more is more active, which is what I try to emphasize with patients. I try not to focus on weight loss, but if they need a measure, how their clothes fit on them. I also try to encourage more fruits and vegetables in general and that frozen works as well as fresh, particularly in winter.

    And if I could get myself and my husband to follow this advice, I think I’d do jumping jacks. Instead we don’t. Definitely a case of do as I say, not necessarily as I do.

    Catgirl, I have no idea what is going on with you, though you are the first person that I’ve heard having the issues that you are. My completely unsolicited suggestion is to see someone who specializes in exercise physiology or may be even a sports medicine specialist (latter being easier to find and get in to see than the former) to see what else if anything could be going on.

  42. #42 Kim
    January 8, 2010

    Catgirl: Just at a guess, I’d say you’re just not challenged by what you’re doing. Without a challenge, there’s no need for your body to adapt, so…

    On the weight-training side, there are a lot of people who’ve been lead to do the same routine with the same weights (usually something like 3 sets of 15 reps with 10lb) for years on end, without progression. I’m not suggesting anyone should run out and pick 200lb up off the floor, but you should feel challenged. It’s also possible that you’re doing isolation exercises (curls, leg extensions, tricep kickbacks, etc. or equivalent machinery) and you would feel better doing full-body compound movements.

    On the cardio angle…my interests have veered away from steady-state cardio, but several years ago when those IOM exercise recommendations came out (an hour per day of low-intensity exercise, I believe), I went to the actual document and did some math. What I came up with was that 200 minutes/week of cardio at 7 METs — about equivalent of a comfortable moderately hard pace (able to speak but not sing, as they say) on an elliptical — met the recommendations. I then looked at the published exercise schedules of about 50 “success stories” (just because they happen to be easy to find and generally pretty normal people) and found that they were typically right at the 200 minute/week mark as well. So that could be one answer on the cardio front: if you’re doing something between 90 and 180 minutes/week, it may just not be enough for you at your existing fitness level to feel improvement.

    The alternative to turning up the time is turning up the intensity. There’s been a lot of good research on high-intensity interval training vs. steady-state cardio in the last couple of years and it appears that a (much) shorter session of intense intervals can be just as effective as a longer session of steady-state (this is also predicted in that old IOM document, although IIRC they don’t address intervals per se as much as activities with varying degrees of metabolic output). If you really enjoy your steady-state cardio keep at it, but if not you might want to experiment with intervals. Something like 15 minutes of 1 minute hard, 2 minutes slow is a reasonable place to start. The studies I’m aware of used a stationary bike, which is probably the safest and easiest option for most people.

    Kind of in the middle are things like fartlek (“speed play”) runs and activities that mimic them. I bring this up because most podcast “coached” workouts fall roughly into this category and I think they’re a great tool for keeping motivated and challenged if you like them. I was a big fan of the Cardio Coach for a while…probably will be again if I find myself unable to skate for some reason.

  43. #43 Peggy
    January 8, 2010

    @#12: In the rust belt, our children teeth on lead window ledges. Our urban gardens grow in raised beds because our cities are built on superfund sites of dredged up sludge and slag and salt that contain toxins we can’t pronounce or measure. We don’t visit culturally-competent primary care physicians who can barely convey the need for lifestyle change in less than 15 minutes – let alone effect the structural change needed to impact individual health. There’s something to be said for social marketing campaigns targeting a fifth grade level of science competency (e.g., “fat is bad”). At least it gets people talking about it. But heaven help the front line.

  44. #44 Professor in Training
    January 8, 2010

    after several months of exercise, shouldn’t I get better at it? Shouldn’t I be able to do it faster or for a longer time? Shouldn’t it become easier to exercise at the same level I started at so I would have to increase intensity to get the same workout? Shouldn’t I feel moderately stronger in some way?

    Depends on what you’ve been doing re intensity, mode, etc. And the HR zones that are preset on HR monitors are based on prediction equations that may not be right for you (they’re certainly not right for me). Again, an exercise physiologist (not a gym instructor) will be able to perform a comprehensive assessment of your strength and cardiovascular fitness and prescribe a program that is tailored to you, your needs and your interests.

  45. #45 Kim
    January 9, 2010

    @Professor in Training: How does one find an exercise physiologist? It doesn’t look like ASEP has a handy “find a member” feature, if ASEP is even the right organization to look at…

  46. #46 DJ
    January 9, 2010

    For some it is not a matter of behavioral changes. For some surgery succeeds where attempts at behavior modification and pills fail.

    It is anecdote of course but I have had 8 people in my family that have undergone Roux-en-Y gastric bypass surgery. This number includes both my siblings, a parent, aunts and uncles and first cousins. All of them underwent medically supervised weightloss regimens prior to surgical approval including dietary changes coupled with excercise regimes, and pills that block the absorption of fat (by all accounts a disgusting experience). All non surgical efforts failed overall in their cases.

    Every single one of them is better off now then pre surgery. In overall health as well as quality of life each has documented improvement. The furthest out from surgery any in my family are is 10 years and doing well at a healthy weight with no comorbidities. So if long term efforts at reducing weight are not working for you and you are obese or morbidly obese please discuss the option with your provider.

  47. #47 Professor in Training
    January 9, 2010

    ACSM is the major accrediting body so this is the best place to search:

    http://forms.acsm.org/_frm/crt/online_locator.asp

    The “ACSM Certified Clinical Exercise Specialist” and “ACSM Registered Clinical Exercise Physiologist” are the best ones to contact.

  48. #48 Professor in Training
    January 10, 2010

    @ Kim #45

    ACSM is the certifying body and you can search for accredited exercise physiologists here. The ACSM Certified Clinical Exercise Specialist and ACSM Registered Clinical Exercise Physiologist are the best ones to choose as they are all college educated in exercise physiology (Masters degrees in the case of RCEP) and are highly trained in exercise testing and prescription for both healthy and diseased populations.

  49. #49 TheDissenter
    January 10, 2010

    How can you find a solution when you don’t even know what the actual problem is? Doctors give out the “eat less and exercise more” advice but haven’t a clue what is going on when it comes to obesity and hold very simplistic assumptions about what the causes might be. Why can one person eat whatever they want, get very little exercise and yet not get fat while another gets fat regardless? The “eat less and exercise more” advice is an easy, naive solution given by lazy thinking doctors who clearly don’t understand the underlying problem. How can the French eat, drink and smoke like they do yet have much lower rates of heart disease than Americans? Could it be our naive medical assumptions were wrong? Of course not, how silly of me!

  50. #50 Cath the Canberra Cook
    January 11, 2010

    There’s a lot of these topics around at the moment – must be the new year effect. And I have a challenge for anyone in the field. (Or anywhere, really.)

    Can you provide me with a single peer reviewed study of any diet and/or exercise program for weight loss that has a 5-year success rate of greater than 5%? I only ask for one. But it must be 5 years or more. So far, I’ve got exactly zip.

  51. #51 spit
    January 11, 2010

    I always wish that doctors would help figure out diet/exercise stuff in terms of overall health, rather than just weight.

    If you say to somebody, if you eat better and exercise more, you’ll be a lot better off overall even if you don’t lose much weight, they’re probably more likely to take it on and notice whether it’s changing their feelings of health, rather than making it about some pound count every week, which becomes quickly disheartening when pounds drop slowly. And it’s likely over time that they will lose some weight if they exercise more and think about their food choices, but even if they don’t lose much weight, they’ll be healthier overall.

    It can be very, very difficult for some people to just “lose weight”. I experienced a major metabolic shift a couple of years ago coinciding with an illness, and it made it clear to me that weight and fat distribution have major physiological components that have jack to do with behavior. My exercise behavior didn’t change, my appetite actually plummeted, and I nonetheless gained nearly 40 pounds over the course of a couple of months, which I’ve never managed to get rid of no matter what I do. It’s anecdote, of course, but at this point, given that experience, you’ll never convince me that behavior is anything more than one factor among many when it comes to weight. Other possible health issues should likely be explored, of course, when weight won’t budge.

    We’d all be better off exercising and eating well whether it leads to significant weight loss or not, though, and I wish that message of overall health was the one that made it through, instead of the constant drumbeat of “you’re fat, lose some pounds” that IMO misses the point. The ultimate goal is not “skinny”, it’s “healthy”. They’re correlated, but they’re not the same thing.

  52. #52 Laura
    January 11, 2010

    In 2006, I returned to see my primary doc because despite the meds, I was still depressed. A stop at the scale is routine on the way to the exam room. He noted the weight gain and discussed his experience with patients falling into this pattern. Depressed,take meds, gain weight, more depressed, increase meds, more weight, more depressed.After discussion and reviewing the criteria (BMI, co-morbid-htn), he referred me to a bariatric surgeon.In July, I had a Roux-en-Y, gastric bypass,covered by my HMO ($300 copay). I think now the lap band is more popular.
    3 1/2 years later, my BMI is 21.0, wear a size 4, and surprise,surprise I’m no longer depressed! It isn’t for everyone, but I feel so fortunate. My experience demonstrated that it really just comes down to calories in vs calories burned.But it is unbelievably complex emotional battle to lose weight, plus the physical hunger that has to still be satisfied. When you feel fat and lousy, the despair sets in and since you already need to lose 100 lbs, whats a few more?
    My point is that my doctor understood the vicious cycle of depression and obesity, and we agreed on the intervention.He could have just increased the meds and said nothing about my weight.
    As an RN, I am familiar with the “non-compliant” label. Nurses and doctors are often the worst patients, since we “know” as much as our treating physician. I discharged a general surgeon after undergoing an outpt knee arthroscopy. We reviewed the d/c instructions and he signed that he understood. As I pushed him in the wheelchair en route to the car, he grumbled that he was cutting his dressing off as soon as he got home! This was a Thurs or Fri. Over the weekend, he was on call and wound up on his feet for about 12 hrs doing emergency surgeries. Well, guess what! Of all the many patients having surgery in our unit, he winds up with a wound infection! Whenever a surgical wound infection occurs,it is scrutinized by the various quality control committees and practically the whole hospital medical and nursing staff gets wind of it.The ortho surgeon had done 2 other arthroscopies that day, and those patients had no complications.Whenever I hear discussion of non-compliant patients, I have to remember that medical professionals are often the worst offenders. Maybe this had something to do with using a less judgmental sounding adjective?

  53. #53 Cara
    January 15, 2010

    That is not to say that all obesity is due to addiction, just that a whole lot of it is.

    What absolute nonsense.

    People are different. For every fatty-on-the-couch who lives on Cheetos (and, NO, there’s nothing WRONG with that because it’s not my business, or yours either) there are at least ten people whose bodies just. hang. on. to. the. fat. Yes, hang on to it, meaning they put it back on even if some goes away, and NOT because the fatty-fatty-two-by-four is eating more or (ye gods) exercising less. Our bodies were DESIGNED to HANG ON TO IT.

    Some natural skinnies point to their weight as evidence of a virtuous life, and it’s a CROCK. Plenty of skinny people have heart attacks and strokes, plenty of them live on the couch, plenty of them DO live on Cheetos, but you just don’t see the evidence of that on their bodies, just like you don’t see evidence of some fatty’s regular breakfast of steel-cut oats and fruit or whatever.

    There IS no evidence, just by looking at someone, what their health is like, and there’s NO evidence that a random fatty has less character or is more of a slob or is less disciplined than a random skinny. NONE.

    Furthermore, multiple studies have shown that not only does dieting not work, but it makes people FATTER than they might have been if they’d been left the hell alone when they were teenagers and put on a few pounds before a growth spurt.

    Everyone has an opinion, nobody has a one-size-fits-all answer. There isn’t one. So stifle it.

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    February 5, 2010

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