Posted tagged ‘obesity’

Doctors Don’t Know Anything

March 16, 2012

My apologies for slacking on writing posts recently…little preoccupied with my own life, but we’ll get to that in another post perhaps. Today, though I wanted to discuss doctor’s lack of knowledge about so much! Recently I saw my neurologist and had a follow-up MRI for the MS symptoms I experienced last year. A year ago, I had an MRI that showed multiple lesions, and a few weeks ago, I was told by my doctor that most of the lesions were gone and there was nothing new! Great news, right? Here is the conversation that my doctor and I had:

Doc: So your MRI looks a lot better…a lot of the lesions are gone…
Me: You sound surprised. Is this what you were expecting in the course of treatment?
Doc: Well, sometimes this happens…
Me: Do you think it’s the medication I’ve been taking?
Doc: Perhaps…
Me: Do you normally see this in MS after starting treatment?
Doc: In some cases…
Me: Can you tell me anything definitive?
Doc: Possibly…

Ok, the last two lines were made up, but you get the idea. My doctor really could not tell me whether I am getting better because of the medication I am taking, the lifestyle changes I’m making, the cinnamon I’m eating, or just the course of the illness. I do understand that MS is an unpredictable illness and often times it is difficult to predict whether symptoms are related to specific findings, as well as response to treatment. In fact although I complain (from a patient standpoint) I also have the perspective of a physician. As a psychiatrist, there are many unknowns about mental health, including its etiology, let alone its treatment. We rely on research studies for evidence-based treatment options, but sometimes there just isn’t any data. We then have to rely on our own or others’ clinical experience to guide us. I often start patients on antidepressants, and the patient improves. Did the patient improved from a placebo effect, the medication, the support and counseling, or even exercise? Hard to say in some cases.

Despite my questions, I am of course happy to be doing better. I feel confident enough that the medication I am taking is helping to some degree, so I will continue to take it. But it’s just a guess.

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Keeping It Off

December 30, 2011

I found this NYT article yesterday about the difficulty of successful weight loss, and finally finished reading it today. I have been interested in this topic recently–the science behind weight loss. Partially I’m interested in this because there is increasing evidence that obesity has underlying biological factors that contribute to its epidemic; i.e. obesity is more like a disease, not a choice. The article is fairly long, but some of the more interesting points I found were the following:

1. There are hormonal changes after weight loss (lower peptide YY and leptin, higher ghrelin) that make it hard to keep the weight off (i.e. someone who used to weigh 150 pounds and now weighs 120 pounds, is different than someone who naturally weighs 120 pounds)

2. Some people have specific genes that make them more predisposed to eat higher calorie foods, and make it harder to lose and keep weight off

3. People who successfully keep weight off are the minority of those who try to lose weight, but they all have specific consistent habits, including tracking their food and exercise, weighing themselves daily, exercising daily, eating breakfast everyday, watching less TV, and not “cheating” on holidays and weekends

4. After weight loss, you are more susceptible to cravings than before (and this is shown on brain MRIs in research, and is some of the evidence behind obesity having similarities to addictions)

5. Knowing some of these things can help to improve ways of losing weight

Now after read this article I feel a bit more informed. It is easy to tell those who are obese to eat less and exercise more. While these tenets are still the core of achieving weight loss, we are starting to learn that not everyone has the ability or the genetics to do this things as effectively or efficiently. That being said, it’s not a reason to give. It may just be that we need to start approaching weight loss for people in a different light, for example slowing it down rather than speeding it up. Another reason to avoid those infomercials late at night!

Good luck and as always feel free to leave comments or feedback!

Obesity Counseling to be Paid for by Medicare

December 1, 2011

Recently I have become interested in the obesity epidemic plaguing our country. I’ve actually been interested in obesity and co-morbid psychiatric illness since residency, but recently my interest has been revived. I read that Medicare is going to be reimbursing health care practitioners for obesity counseling and screening. My initial thought was that this is a positive step in the right direction. But the cynic in me began to wonder–what does obesity counseling exactly consist of? Who will be administering this counseling? Will it be nurses, doctors, nutritionists, or psychologists? What data is available that tells us this will actually work?

Currently, the art of “counseling” is already in danger of becoming an extinct entity, as a result of changing insurance reimbursements, which tend to be better for psychiatrists who prescribe medications rather than psychotherapy. This has influenced the state of psychiatry training programs, which have begun to deemphasize training for therapy, favoring instead a focus on psychopharmacology and biology. This has its pros and cons, as with anything, but has turned psychiatrists partially into pharmacists. I find it unfortunate.

But back to obesity counseling. Usually now, when obese patients see their doctors, they hear a lot of the same information over and over again–that obesity leads to hypertension, diabetes, strokes, heart attacks, shorter life expectancy, and so on. To deal with obesity, patients are told to eat healthier and to start exercising. Well, no kidding! All of this information is now readily available anywhere online and is not news to people. So what makes doctors think that repeating this information will all of a sudden get a patient to lose weight? It doesn’t. Which leads to no change, which in the long run, makes doctors become pessimistic, believing none of their patients will change. So they start treating the diabetes and high blood pressure, ignoring the underlying obesity, and it turns into one big never-ending cycle.

I hope this is not what “obesity counseling” will consist of. I hope that what doctors and other health care practitioners start learning is that motivational interviewing and motivational therapy is the way to get patients to start changing. We have to allow patients to tell us why they want to change, not us tell them why they need to. People only change when they are ready to. We need to start learning how to get patients to get closer to that point. It’s easier said than done.