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Fighting obesity means fighting evolution's urges to gorge

From the June ACP Internist, copyright © 2012 by the American College of Physicians

By Jennifer Kearney-Strouse

To fight obesity, physicians and patients must fight evolution, according to David S. Tichansky, MD, associate professor of surgery at Thomas Jefferson University in Philadelphia.

“We're all genetically programmed to eat as much as we possibly can at every possible opportunity, and when we're given a choice to select the sweetest-tasting choice,” he said at his session on “Obesity: The Disease and Its Management” at Internal Medicine 2012 in April. “That is what our brains want to do. That's what we're up against.”

Dr. Tichansky

Dr. Tichansky



To help combat genetics, as well as contributing psychosocial, societal and cultural factors, Dr. Tichansky said that physicians should start early, be proactive rather than reactive, and incorporate discussions of activity and nutrition into every visit.

“When you first meet folks, you'll see the evolution of a BMI [body mass index] of 25, then their BMI is 27, 28, 29, 30, it just keeps marching up,” he said. “To jump on somebody when their BMI is 35 and you say ‘You know, you're really overweight,’ they're going to lock you out. You're not going to be a good team, and that's going to be hard to treat.”

Talking about weight is often easier said than done, Dr. Tichansky acknowledged. It can be difficult for physicians to bring up a patient's weight, so they often just avoid the subject. Also, many obese patients don't realize they're obese.

“If patients are asked what they think about their weight, a lot of them will say, ‘Well, I think I'm fine,’” he said. “You have to get your patients to see the extra weight and then have an educated discussion about it.”

Activity is an important component in losing weight, Dr. Tichansky said, and while activities of daily living help, they aren't enough. Metabolic activity is the goal, and adding and using muscle mass is the best way to be metabolically active.

He stressed, “You not only have to add the muscle. You have to use it.”

He recommended telling patients to break up their activity into shorter time frames in order to burn more calories. Often, if physicians recommend an increase in exercise, patients will offer to increase their cardio from 20 minutes to 30.

“Don't do that,” Dr. Tichansky said. “If you have 30 minutes, which is the hardest part, do 10 minutes of something else.”

Good food, good fuel

He also discussed the importance of diet and nutrition and how to communicate that to patients. “What society thinks of as good food is generally not good fuel,” he said. “Now, good food can be looked at another way, which is that nutritious food is good fuel.”

Physicians should get patients in the habit of distinguishing between “brain hunger” and “stomach hunger,” Dr. Tichansky said. Ways to do that include controlling portion size, chewing slowly, eating “free foods” like carrots and celery, and waiting 20 to 30 minutes before eating something else.

“Use your brain to think about food all the time,” he said. “Is this something good that I'm putting in my mouth? Do I need it? And is it going to help me or hurt me?”

Tell patients that when they serve themselves food, they should still be able to see the plate. The ideal meal to aim for includes mostly lean protein, about 50 grams per day, and veggies, Dr. Tichansky said.

“You really want to start educating your patients about protein. Unfortunately it's the most expensive, but it's what you want to push first,” he said.

Dr. Tichansky noted that the ideal meal does not include many (if any) additional carbohydrates. “Fiber's OK, but you don't necessarily need to add carbs. Carbs are just a bunch of sugars holding hands,” he said.

Likewise, physicians should tell patients to take it easy with fruits, he said, because although they're flavorful and a good source of vitamins, they're packed with calories. A good limit is two cups per day.

Recommend whole grains rather than refined grains, he said, and urge patients to limit oils and fats to six teaspoons per day. Patients should aim for at least three servings of low-fat or fat-free dairy a day. Physicians should also teach patients to read nutrition labels.

“Calories are what you're paying, and protein is what you're getting,” Dr. Tichansky said. The rule of thumb is fewer than 20 calories per gram of protein, he noted.

Realistic expectations

Beverages can be a minefield for anyone trying to manage their weight, Dr. Tichansky said. “If you can impress upon your patients ‘Don't drink calories,’ they will lose weight. I can almost guarantee it,” he stressed. “Most folks drink hundreds of calories a day.”

Other catchphrases can help patients, too, he said. Remind them that muscle burns fat, and that an extra 100 calories per day will add up to a gain of 10 pounds in a year. Also point out that “Most food either helps you or hurts you,” Dr. Tichansky said. “There's very little in between.”

Patients should be encouraged to set realistic expectations, Dr. Tichansky advised.

Getting patients to take one sustainable big step every few months, such as not drinking their calories, is better than trying to change everything at once, he said. Another potential big step is helping patients learn the dangers of what Dr. Tichansky called “death on a plate,” foods with an unspeakable amount of fat and calories.

“It's not that you can't ever eat bacon ice cream,” he said. “But you have to think about it and know you're doing something wrong. That's part of what you have to impress on people.”

Treatment algorithm

Dr. Tichansky recommended a BMI-based treatment algorithm for managing weight in primary care. Basically, he said, everyone, no matter what their BMI, needs to be thinking about maintaining a healthy weight. Patients with a BMI of 25 to 30 kg/m2 should start trying to bring the weight down themselves through diet and exercise.

When patients hit a BMI of 30 to 35 kg/m2, however, more intense supervision is needed. Diet and exercise are a given, and medication may be necessary. At this point, Dr. Tichansky said, patients should be visiting their physician monthly to help manage their weight, and a personal trainer and a dietitian should probably be involved.

“You have to stay on these people, because if you say ‘Eat less and exercise more, I'll see you next year,’ it's not going to happen,” he said.

Patients with a BMI of 35 to 40 kg/m2 will need medication for weight loss in addition to diet and exercise, and for patients with a BMI above 40 kg/m2, surgery will be necessary, he said.

“Yes, I do surgery for end-stage obesity ... but I'm really just presenting this stuff in the context of efficacy,” Dr. Tichansky said. “Statistically, it's extremely unlikely for somebody who reaches that last BMI of 40 ... to get significant and sustained weight loss without surgery.”

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