We have heard the often repeated statistics from the Centers for Disease Control and Prevention that nearly 34 percent of American adults are obese, and an additional 34 percent are overweight. Another report has shown that in nearly two-thirds of states, more than 25 percent of the adult population is obese. We know that being overweight or obese increases the risk of developing various diseases that either directly or indirectly impact the lower extremities, including type 2 diabetes, hypertension, metabolic syndrome, cardiovascular disease, certain cancers, and osteoarthritis.
It has been shown that physician counseling can positively impact patient’s behavior related to weight loss, and podiatrists should be part of a public health team approach involving multiple health care providers working toward reducing the numbers of prediabetic overweight and obese people in our country. As we know all too well, many overweight and obese patients have co-morbid conditions requiring treatment by a number of specialists. The foot pathology that often accompanies the obese patient is a prime example. It is a natural fit for the profession that maintains the foot and ankle health necessary for an active lifestyle that can help prevent obesity, and its unwanted health problems, but we have to be willing to engage our patients in this discussion.
We often serve as a patient’s primary contact with the health care system for their foot or ankle problem. We see overweight patients of all ages with musculoskeletal stress and strain pathology related to excess body weight, as well as those with diabetes and other disorders associated with “pre-diabetes” or metabolic syndrome. Podiatrists see the direct effect on foot and ankle structure and the dynamic biomechanical dysfunction often associated with an elevated body mass index. We can show the patient exactly what is happening structurally to their feet, as opposed to trying to associate the more abstract insulin resistance, for example. We should also inform our patients about the indirect metabolic effects of poor blood sugar and lipid levels, such as peripheral diabetic neuropathy (PDN), peripheral arterial disease (PAD), and stasis dermopathy. As podiatrists we should use the important patient-physician relationship to demonstrate the direct and the indirect impact of an elevated BMI, and its resultant lower extremity comorbidities, both “visible and invisible.”
Many of us are weighing our patients as part of electronic health record (EHR) meaningful use. Why not make this data collection truly meaningful? Why not use this parameter to engage your patients in discussions about weight, even just a little bit. Doing our part in assisting our patients toward steady improvement in not only BMI, but in its associated health problems is a good way to encourage patient motivation toward improved overall health. We need to help our patients understand metabolic related health problems, such as blood pressure, glucose, and cholesterol levels. Discuss how abnormalities in these values can affect the lower extremities leading to PAD, PDN, DM, venous insufficiency, etc. An elevated BMI and its stress on the lower extremity tissues results in the negative cycle of metabolic related pathology and pain with decreased mobility leading to additional increased weight, additional metabolic pathology and lifestyle alterations…and the cycle continues. Patients who understand the health risks associated with an elevated BMI may be more motivated to undertake lifestyle changes and use the foot and ankle health care that we provide to become more active.
Connect with dietitians, nutritionists and exercise specialists in your area and consult these specialists to promote the multi-disciplinary approach needed in this often complicated area of health and wellness.
I realize this is a discussion that many of you simply do not want to have. Despite the fact that studies have shown that physician motivation can be helpful, studies also show that screening and counseling for obesity is not occurring regularly during physician visits. Physicians generally prefer to treat the resulting health conditions rather than encourage patients to lose weight, under the assumption that it is a waist of time, and any weight loss, and the resultant health improvement, will not be maintained over time.
Other factors physicians cite include:
- The lack of effective treatments and appropriate reimbursement for their effort.
- The belief that patients would not succeed anyway and it’s a waste of time.
- Opinions about the origin and responsibility for obesity.
- Physicians also tend to give low ratings to their ability to treat obesity because they might lack confidence in their weight counseling skills.
- Some physicians believe weight loss to be futile and dieting cycles dangerous for obese patients without co-morbidities.
Yes, clinical management of this problem can be discouraging, but one never knows when or how a patient may be motivated to actively engage in weight management. Finding the right weight loss motivation and approach for each particular patient is challenging for all health care practitioners. Obesity is a complex condition caused by a combination of factors and each patient needs to be addressed independently. So, how do we effectively go about this? Broaching the subject of obesity can be a complex issue, and patients are at times unprepared to begin this discussion and the necessary recommendations. Evaluating a patient’s “readiness for change” is an important function of the doctor-patient relationship. Listen for verbal cues. Readiness for change assessment is the patient’s willingness to attempt even small lifestyle changes, such as your diabetic patient acknowledging that his blood sugars have been better because he stopped eating so much ice cream.
We also need to develop various methods to motivate patients toward improved health. One example is the use of a pedometer to motivate walking exercise. This is a good device for patients to gauge the small incremental improvements in beginning a more active lifestyle. We really haven’t incorporated these devices into our practices despite the literature demonstrating their benefits – quick examples of recent studies here, here and here. Encouraging patients to focus on making a few small lifestyle changes, rather than completely overhauling current behaviors, sets them on the right track for weight management, some physical movement activity and improved health.
In addition, as I implied above, we need to expand our patients’ conception of weight loss to include thinking about weight management in terms of health rather than appearance.
Realistically addressing false expectations of success is also essential to weight management. Make sure the patient has a realistic goal. Many patients embark on a weight loss lifestyle with high expectations of success, and then become discouraged after weight loss slows or plateaus. There is evidence that patients who set smaller weight loss goals have better weight loss outcomes than those who expect to lose a large amount of weight rapidly. Help your patients set realistic expectations for weight loss by clearly defining an acceptable goal of 5-10 percent of total body weight. Patients need to understand that small incremental weight loss is perfectly acceptable. They need to understand that even modest weight loss significantly improves health outcomes, including reducing the risk of developing type 2 diabetes, dyslipidemia, hypertension and cardiovascular disease. Explaining the clinical significance of modest weight loss may also help patients focus on health benefits rather than appearance, although some patients may be better motivated by improved appearance—whatever it takes.
Although some aspects of weight management are currently beyond the scope of our evolving education and training, some degree of diet and exercise guidance is appropriate. This discussion need not be extensive and time consuming. Briefly explaining and emphasizing the general health risks and the deleterious effects on the lower extremities of excess body weight and its comorbidities could motivate patients to manage their weight. Develop professional relationships with weight management specialists in your medical community.
As the prevalence of medical conditions associated with an increased BMI continue to rise, and the resultant costs of treating the associated health conditions continue to rise, efforts to treat and prevent metabolic dysfunction, and its often associated elevated BMI, have become increasingly important. This open letter and web site is one effort toward that end.
*This open-letter was partly inspired by the paper from the STOP Obesity Alliance Research team at George Washington University entitled, “Improving Obesity Management in Adult Primary Care.”