The Patient Was…

Obesity is big.

Duh!

Seriously, obesity is big in several ways. Obesity is big business. Obesity is a big economic issue.  Obesity is a big socio-cultural problem. Obesity, perhaps most importantly, is a really big health concern.

The economics around obesity are staggering. Obesity-related direct medical expenses, including doctor visits, drugs, tests, treatments, etc., are estimated at greater than 260 billion dollars yearly. Adding indirect costs, such as loss of productivity, brings the total to over 400 billion dollars. Obesity raises medical costs for all of society because public programs and insurance companies carry much of the extra financial burden of obesity-related illnesses.

Despite the fact that obesity has been officially recognized as a chronic medical condition, many social and cultural stigmas remain. Obese people suffer in employment opportunities, salary negotiations, and social acceptance. Obesity is still regarded by some as a moral or personality issue, a problem of personal choice or indifference, or one of simple willpower.

 “Fat-shaming” in public places still exists. Well-intentioned efforts to combat it can sometimes have unexpected and embarrassing consequences. The bright young daughter of a dear friend, who was taught never to comment on people’s physical characteristics, was in an elevator with her mother when a very obese woman entered. The child turned to her mother and said loudly, “Mommy, it’s not nice to say that people are fat, right?”

My own experience with weight has been both personal and professional.  As a child, I was always skinny; excess weight was never an issue. As an adult, as years went by, I tended like many people to gain weight; It just sort of crept up on me. Less physical activity, a wife who cooked deliciously, dinners out, big social occasions, all contributed. Still, I never thought of myself as being overweight. I never weighed myself.

One morning, dressing for the office, I had trouble buttoning my shirt collar. I was sure that the button had come loose at the dry-cleaner and had been incorrectly replaced. Then, looking in the mirror, I realized that I was jowly and my neck was fleshy. I got on the bathroom scale and was appalled by the reading. In an instant, I vowed to go on a strict diet.

And did I do it!

Over the next three months, I l.ost 60 pounds. (I ate so many tomatoes my palms developed an orange tinge and a blood test confirmed I had carotenemia, excess levels of a vegetable and fruit pigment called carotene in my blood). When I started to look gaunt and drawn, I stopped the diet, regained some weight, and looked normal again. At this point, many of my patients told me they thought I had a terminal illness when I had gotten so thin, others thought I was having a mid-life crisis and was having an affair, and a few thought both.

My more professional involvement with obesity occurred when I was Medical Director of a major pharmaceutical company that was going to introduce an anti-obesity drug into the global marketplace. The drug was not very effective and had unpleasant and sometimes unpredictable side effects. But, at the time, there were not many good alternatives as there are now with newer and very effective medications.

One major problem dealing with obesity then was the discrepancy between the amount of weight loss yielding medical benefits and the weight loss expectations of physicians and patients. Believe it or not, measurable health benefits occur with as little as five percent of body weight loss. But physicians were interested in fifteen percent of body weight loss for their patients. And patients themselves were seeking twenty-five percent loss of body weight. Nothing in the market came close to those physician and patient hopes.

Still, the company felt there was a market out there, if we could show more people that they were, in fact, overweight and that a medication could provide health benefits.  First, the doctors needed to be convinced that many of their patients warranted treatment even though their wishes for greater weight loss were not met.

In my discussions with practicing physicians in their offices, the doctors often made the point that few of their patients were actually overweight or obese. But estimates of the U. S. population said that a very large percentage of people were overweight or obese. (Those figures are now about seventy percent). Well, I thought, if such a large percentage of the population was, in fact, overweight, where were they if not in doctors’ offices? The answer was that they were there but not recognized. And the reason was that medical obesity is defined by measurements and calculations, and not by simply looking at a person who seems to be an average, “normal” individual.

Obesity, in its basic form, is a matter of excess fat in the body. While there are scientific methods of actually measuring body fat content, they are neither simple nor readily available. For years, the official means of diagnosing obesity was a measurement called Body Mass Index, or BMI. This was a mathematical calculation that depended on the ratio of your weight to your height. The range of normal was narrow and, depending on their BMI, people were variously categorized as underweight, normal, overweight (pre-obese), obese, and morbidly obese.

Since so many people were overweight or mildly obese, and could benefit from as little as five percent weight loss, it was important to make physicians aware of this. But the doctors were simply looking at who seemed to be normal people and not recognizing that they were in the overweight or slightly obese categories.

If the physicians saw somebody who looked overweight or obese, they believed it and acted accordingly. The problem was they weren’t seeing it so they didn’t believe it. I decided we needed a reverse strategy. Rather than acting on the age-old adage Seeing is Believing, I emphasized the reverse. Believing is Seeing. In other words, if the doctors believed that a lot of their patients were overweight, they would recognize them as such and address the weight issue. I would ask the doctors to believe that many of their patients were over the normal BMI level, and then I would accompany them as we looked into the waiting room. And the physicians began to recognize that a lot of the people sitting there probably were, in fact, over the healthy BMI limit.  

BMI has recently fallen into disfavor as a criterion of obesity because some people can be falsely categorized by the calculation. A heavily muscled individual, for example, with little body fat can still have a high BMI and be considered obese when they are not. And people with excess body fat but low muscle content and bone weight can still have a normal BMI. More recent definitions of obesity depend on things like waist-to-height ratio and waist-to-hip ratio, as these more accurately detect fat distribution in the body. Waist circumference itself is an important measurement: for metabolic health it should be less than forty inches for men and 35 inches for women. It is known that fat around and within the abdomen is linked to higher risks of heart disease, diabetes, and other metabolic disorders.

Obesity is a chronic illness. There is now greater understanding of it than there ever was. And there are now more and better solutions to the consequences of obesity than ever before. Be aware and take advantage of new knowledge.

And remember, in this and other things, Believing is Seeing.