Changing How Doctors View Obesity

Source: Lisa Young/Photodune

Our modern obesity epidemic causes significant emotional pain and physical disability and is associated with numerous serious health risks. Sadly, our health care system as a whole continues to struggle to meet the medical and psychological needs of people suffering with this condition that now affects 40% of American adults and 20% of American children, according to the CDC.

Providing effective, compassionate, respectful care begins by fundamentally altering the way we healthcare professionals think about obesity. If we set aside the tired, unhelpful belief that obesity is caused by over-eating and under-exercising—and replace it with scientific understanding about root causes, we can not only provide hope and help for people already afflicted with obesity, but also potentially begin reversing global trends by educating people about how to prevent obesity in the first place.

We need to understand that obesity does not cause health problems like Type 2 diabetes and heart disease—instead, we need to view obesity as simply one of the many conditions caused by underlying insulin resistance.

The majority of office visits to generalists and specialists alike are centered around the management of conditions related to insulin resistance, including:

• Hypertension
• Type 2 diabetes
• Depression
• Obesity
• Alzheimer’s disease
• Non-alcoholic fatty liver disease
• Heart disease
• Erectile dysfunction
• Polycystic ovarian syndrome
• Acne

Learning about insulin resistance, therefore, helps all of us to improve the health of all of our patients.

Unfortunately, most health care professionals don’t know how to evaluate patients for insulin resistance, focusing instead on ruling out type two diabetes by measuring simple fasting blood glucose and hemoglobin A1C levels. By the time these are elevated, type two diabetes has already arrived. We need to identify people at risk for serious insulin-resistant conditions like diabetes, heart disease, Alzheimer’s before these diseases take hold. This means looking at early markers of insulin resistance such as elevated fasting insulin and triglyceride levels, central adiposity, rising GGT, elevated hsCRP, and low HDL.

The reality is that most physicians know very little about nutrition and how food affects one’s health. I personally received just a few hours of nutrition education during my four years in medical school, and nutrition was never discussed during my four years of psychiatry residency, even when learning about how to approach eating disorders.

With more than 50% of the population now suffering from insulin resistance and resultant diseases, lack of education is no longer an acceptable option. Medical professionals need to learn how insulin resistance works, how to screen for it, and how to help their patients manage it. We must stop blindly recommending low-fat, plant-based, or Mediterranean diets—none of which are designed with insulin resistance in mind—and begin implementing treatment strategies that effectively target insulin resistance.

Having reflected on related topics in my companion post entitled Obesity: Stop Shaming, Start Understanding, I thought it might be helpful to share some strategies I’ve developed based on both my experiences as a patient and as an integrative psychiatrist that have made a difference in the effectiveness of my own clinical work.

1. Don’t assume people with obesity have come to your office seeking help losing weight. Identify people’s health goals and meet them where they are.
2. Ask permission before discussing obesity and food with your patients. These can be exquisitely sensitive and difficult subjects for some people.
3. Don’t pretend to possess knowledge or expertise you don’t have. Acknowledging limitations goes a long way toward building trust and respect, particularly when compared to guessing or giving bad advice.
4. Focus on nutrition and health, not weight. People with obesity know they are overweight and don’t need to be reminded of that fact. Consider the risks and benefits of weighing everyone at every visit. People with obesity may dread the office scale—often to the point that they avoid medical care until there’s an emergency. Once someone is on the right track and making progress, they may look forward to weigh-ins and even volunteer to step on the scale. Until then, it may be better to focus on less emotionally charged measures of metabolic health such as insulin, triglycerides, and HDL. While there is no single agreed-upon best test for insulin resistance, this inexpensive lipoprotein panel is worth considering. See also my article entitled “How to Diagnose, Prevent and Treat Insulin Resistance.”
5. Asking someone with obesity to exercise more is not usually an effective initial intervention. As inflammation and weight start to come down, people are more likely to be able to comfortably incorporate exercise.
6. For people with insulin resistance, healthy weight management isn’t simply about eating less and exercising more; it’s about finding natural, sustainable ways to lower insulin levels. Helpful strategies include whole foods diets, low carbohydrate diets, ketogenic diets, zero-carb carnivore diets, intermittent fasting, strength training, or some combination of these. Most of these strategies can be plant-based or include animal foods, depending on patient preference.
7. Learn which medications raise insulin levels, cortisol levels, or cause weight gain and work with patients to reduce or eliminate those medications. Examples include antidepressants like Zoloft, antipsychotics like Risperdal, mood stabilizers/anticonvulsants like Depakote, and glucocorticoids. There is more information about psychiatric medication management here.
8. If you are overweight yourself, don’t let that stand in the way of offering guidance to your patients. While you may assume that people will discredit you for being overweight, your shared experience, your humanity, and your personal investment in the subject can be a powerful tool for building trust and strengthening the clinical alliance. In fact, many with obesity are unlikely to trust weight loss advice from clinicians who have never been overweight themselves.
9. If you don’t enjoy, feel comfortable, or feel confident working with people with obesity, seek specialized training and/or counseling to improve your skill and comfort level. In the meantime, refer out to specialists or collaborate with trusted colleagues. Please note, however, that most conventionally-trained dietitians are not taught about insulin resistance and rely on the same epidemiologically-derived guidelines that have been destroying public health for decades, so choose your nutrition colleagues carefully.
10. Invest time and resources in insulin resistance education—not just for yourself and your patients, but also for your staff. Insulin resistance and obesity are very common among nurses, phlebotomists, technicians, and other healthcare workers. Healthier, more knowledgeable colleagues will not only be an asset to your practice but can serve as powerful role models for your patients.

There are many resources available to help in your efforts. Three of my favorites are:

• The Obesity Code by Jason Fung, M.D. I recommend this book not necessarily to learn about fasting strategies, but primarily because Fung makes a well-referenced, thorough, and airtight argument for the role of hyperinsulinemia as a major root cause of obesity.
• Why We Get Fat by Gary Taubes.
• For an excellent presentation about how powerful insulin resistance interventions can be for obesity and Type 2 diabetes, I enthusiastically recommend this (viral) TEDx talk by Sarah Hallberg, an obesity and diabetes expert clinician-researcher: Reversing Type 2 Diabetes Starts With Ignoring the Guidelines.