Recently I attended a CME presentation on hypercholesterolemia, diabetes, and cardiac disease. One speaker pointed out that successful treatment of those diseases often involves getting patients to lose weight and suggested that we clinicians should be examples to our patients. However, many of us do not practice what we preach and may be overweight or obese ourselves. Another presenter actually said that while it would be nice for patients to lose weight, let's face it, they won't—and then recommended medications to treat the medical complications of obesity.

I am sure that as health care providers, you would agree that obesity has reached crisis levels in the United States. A November 2007 CDC report concluded that 33% of adults are obese,1 and data from the 2003–2006 National Health and Nutrition Examination Survey showed that obesity was up to 18% in children.2 The direct costs associated with obesity represent 5.7% of our national health expenditures.3 Given that more than 5% of medical spending in US adults is attributable to obesity,4 shouldn't we be trying harder and better to help our patients lose weight?

I have seen my share of obese patients as a PA who works with an internal medicine physician to treat weight problems. Six years ago, my supervising physician collaborated with a dietician to develop a comprehensive 12-week eating plan. The first two weeks are limited to high-protein foods and green vegetables. The remaining 10 weeks add in whole grains and fruits. Patients can choose whether to follow a specific menu or select from a list of approved foods in specified portions. Eating snacks to control hunger and drinking lots of water are emphasized. We often customize the eating plan, depending on the patient's progress and lifestyle.

At the start, each patient has a complete physical examination, with laboratory tests and an ECG; receives exercise education with instructions; and is given a serotonin supplement that the physician developed along with the anorectic phentermine. The initial visit is often covered by insurance. Patients are evaluated and counseled weekly, which provides the reinforcement they need to keep going and ensures their medical well-being. On average, patients lose 25 to 35 lb during the 12 weeks. We have seen more than 7,000 patients reach their weight loss goals.

Yet in spite of our successes, my colleagues have been skeptical—even cynical. I hear that all we are interested in is making money and that “diet pills” are dangerous. I argue that it is money well spent when compared to the cost of bariatric surgery and remind my colleagues that we teach patients how to eat properly and exercise and help them to understand why they became obese in the first place. When was the last time you were able to sit with your patients and actually have a discussion only about their eating habits? And as for the medications, they help. Patients have already tried alternative diets, which is why they come to us.

Isn't it more ethical to give our patients a plan with the tools that can help them succeed than merely to state the obvious need for weight loss and exercise at their annual appointment? For me, what we do is akin to helping a patient to quit smoking, which can also involve treatments that carry some risk and depend heavily on the individual's motivation and behavior. It may be easier to prescribe drugs that can aid smoking cessation because most of us don't smoke. But every one of us has likely thought of our waistline from time to time.

I admit that when I interviewed for my position I, too, looked on with a cautious eye. But after much scrutiny of the program, I abandoned my comfort zone and embarked on something new. I hope that you all might reconsider a more comprehensive, aggressive treatment for obesity. Could your practice develop an in-office program for your obese patients? Could you make appointments solely to counsel patients on diet and exercise, as we do? Our patients pay out-of-pocket, and your patients might consider it, too. I'll bet that if you asked them, they would admit to paying for some commercial weight loss program. You are their trusted provider, and you have their best interest at heart. They need accountability and consistency to stay focused on an eating and exercise plan. It's extremely rewarding to see patients succeed in reaching their goals—and to thereby succeed in achieving our goals in the treatment of obesity: the prevention of disease and the promotion of good health. JAAPA

Elizabeth McPhilomy practiced at Potomac Internal Medicine Associates, Burke, Virginia, whose business is 30% internal medicine and 70% weight loss, when she wrote this article.

REFERENCES

1. Ogden CL, Carroll MD, McDowell MA, Flegal KM. Obesity among adults in the United States—no change since 2003–2004. NCHS data brief no 1. Hyattsville, MD: National Center for Health Statistics; 2007.

2. Prevalence of overweight among children and adolescents: United States, 2003–2004. National Center for Health Statistics Health E-Stats. http://www.cdc.gov/nchs/products/pubs/pubd/ hestats/overweight/overwght_child_03.htm. Accessed February 10, 2009.

3. Wolf AM, Colditz GA. Current estimates of the economic cost of obesity in the United States. Obes Res. 1998;6(2):97–106.

4. Finkelstein EA, Fiebelkorn IC, Wang G. National medical spending attributable to overweight and obesity: how much, and who's paying? Health Aff (Millwood). 2003 Jan-Jun;Suppl Web Exclusives:W3-219-226.