Fat new patients

[Lordosis]

This is more of a rant then a question but so be it.

I am still taking new patients as I am 3 years our of Family Medicine training.  New patients present a lot of challenges and some have some real complex medical problems to wrap your head around.  Especially being a PCP and taking all comers almost anything can come through the door.

This is not new but I just had a few variations of this in the past few weeks.  Objectively healthy people (other then obesity) come in complaining of being fat and their last doctor did nothing to help them.  I look through their records and see dozens of thyroid labs and other basic panels.  At first I tried to play along and look for medical reasons for obesity but it never pans out.  I can say never in this case because I have not seen it but I am sure it really happens rarely. Most of them have never been part of any formal diet and they do not like the idea of starting one.  Everyone wants that magic pill.

My most recent tactic is to have them keep a food diary and review it on our follow up.  Most people either do not come back or come back but did not follow through on the diary.  One person brought me a diary showing an average of 4500 cal a day.  We made some changes and he has had some modest success!

I would love to hear from other PCPs out there if you get similar issues and how you handle it.

Other specialists-  What are your versions of this kind of situation?

I actually do consider myself a good and caring doctor.  That is why I am venting my frustrations here rather then at my patients :P

[Peds]

Lordosis wrote:

see dozens of thyroid labs and other basic panels.

Click to expand...

ugh. what a waste....

thankfully peds a little different....definitely nutr/behavioral referrals.

getting parents/kids to realize that what they are doing is the problem is a big part. ie a kid with a BMI of 99% (but no come nada doctor! .... si, el come mucho!)

i can think of a few patients over the years i have sent endo stuff, but more because of height issues, or physical findings.

im assuming you also mean A1C, AST, lipids, etc are normal? cause if not id really harp on that being abnormal and they are no longer "healthy"

 

i for one still favor using the clinical terms: overweight, obese, morbid, etc. but not fat. the kids always end up quipping back "so you are saying im fat?" to which the answer is "no, you just have too much of it"

[Lordosis]

Peds wrote:

Lordosis wrote:

see dozens of thyroid labs and other basic panels. 

Click to expand…

ugh. what a waste….

thankfully peds a little different….definitely nutr/behavioral referrals.

getting parents/kids to realize that what they are doing is the problem is a big part. ie a kid with a BMI of 99% (but no come nada doctor! …. si, el come mucho!)

i can think of a few patients over the years i have sent endo stuff, but more because of height issues, or physical findings.

im assuming you also mean A1C, AST, lipids, etc are normal? cause if not id really harp on that being abnormal and they are no longer “healthy”

 

i for one still favor using the clinical terms: overweight, obese, morbid, etc. but not fat. the kids always end up quipping back “so you are saying im fat?” to which the answer is “no, you just have too much of it”

Click to expand...

Just to be clear I do not call my patients fat.  I use more sensitive wording as you illustrate.

Yes those labs are a waste.

I am glad you reminded me of the claim that "I eat nothing, like only 1200 calories a day"  That is what triggered this food diary tactic of mine.  Not that it is proof to me but more proof to themselves.  (Not bad for my last Spanish lesson being in 8th grade)

[Panscan]

Like you said the food diary probably isn't even accurate for most. All kinds of creative accounting, those 3 spoonfuls of peanut butter don't care, even though it's like 300 cals.

It takes tough love and understanding the biochem involved. It also takes the patient realizing what they're doing is causing their obesity, so no matter how well informed or good you are, if they can't accept that then you probably won't get anywhere.

Research shows that BMRs between normal people fluctuate up to like 300 calories a day, which is not the difference between between 300 lbs and 150(although people love to claim it is). I also think we vastly overestimate how many people have metabolic disorders which cause them to be obese.

[CordMcNally]

A lot of these people just need their physician to be up front with them. You're not going to make very many friends but you'll change a few of their lives.

[FIREshrink]

Have you read Crucial Conversations? Be honest and direct, but kind. You can do it.

[Tim]

https://www.spanishdict.com/translate/muy%20gordo?t=1

With society’s shift to acceptance, appearance and physical attributes are “off limits “, negative feedback is deemed as harmful (at best).

The “code” used to be percentile’s. Too high or too low was a potential problem to be addressed. With vanity and self improvement out of favor, good luck.

“You need to lose weight. Eat balanced meals and exercise.”

It’s not your fault Lordosis!

[MPMD]

I don't mean this as bad as it sounds, obviously it's hard to type out your tone.

I think if I were in primary care I would be tempted to deliver something along the lines of, "as a primary doctor it's difficult for me to truly counsel patients on weight loss. the steps to weight loss are well known and I can't take up valuable time at our visits reviewing them, we are going to focus on other aspects of your care and if you need a physician to counsel you on detailed steps of weight loss I'm happy to refer you to a specialist."

You guys are dealing with HTN, HL, and DM up to your eyeballs to say nothing of smoking cessation, chronic pain, and that's before we even talk about routine health maint. I have no idea how you would have time to create individualized weight loss plans.

[ctt209]

Hi, first time poster, long time lurker on the forums (didn't think my first post would be about medicine instead of finance!)

I'm primary care as well. What I've been doing with my patients is

First get a gauge of what kinds of diets they've been on before. Usually it's some sorta fad diet/or crazy yoyo dieting or weird combo of "cleanses" and downing a bunch of apple cider vinegar. I do this 1) to get a rough understanding of the patient's health literacy, and 2) make the pt feel as if they're being heard and thus take whatever advice I give going forward more to heart.

I then ask them what their daily schedule/ routine is like, when they wake up and how many meals they eat etc, when they sleep, as I sometimes have a lot of night shift workers or truckers, and so giving them diet tips has to be somewhat grounded in reality/ limited by their work schedule.

Lastly, similar to you I do some calorie counting exercises with them. I first calculate their basal metabolic rate, to get a rough estimate of how many calories they need to eat to maintain their current body weight. I then tell them that healthy weight loss is losing 1 lb/week (not more than that). 1 lb of fat is roughly 3500 calories, so that means they have to be net negative 500 calories a day roughly. I then tell them to download either my fitness pal or lose it app on their phone and take a day or 2 and eat the way they normally do, except they have to log everything they eat, that way they get a rough estimate of how many calories they're over eating. I then tell them to change the sequence of eating, as it takes 15-20 min lag time from when your stomach is full to when it sends the signal to your brain to stop eating. I tell ppl to get a large tub of spinach salad mix from Costco, cut up some carrots and cucumbers and eat it with hummus. When they first come home from work/ or feel ravenous, instead of binge eating chips/cookies, to eat the salad/veggies until they feel full. While they're doing that I tell them to cook their protein (usually frozen salmon filet that I tell them to get from Costco as well), so by the time they're full off the veggies, then the protein's ready to eat and then I tell them to eat their carbs (breads/rice).

I then ask the pt to also try to incorporate some calisthenics/home exercise routine, even if for 10-15 3-5x/week somewhere during the course of their day.

 

That's roughly the gist of it, and I send them to a nutritionist as well, and also screen them for OSA, as the vast majority of these ppl are gonna be positive for it.

[Zaphod]

I think you're doing it the right way. A food journal is an amazing way for people to wake up and see they are the actual problem. Also helps them to see what is what calorie wise.

I usually have a little chat about choices and try to frame it in making better choices every day. A little less dinner for starters. Drop the sugary drinks some. Start with volume reduction or whatever is easiest to the pt. When thats normal make another better decision. It wont be quick but its sustainable month/month and year over year those good decisions compound and all the sudden you've lost weight and are much healthier.

Obviously have a lot more conversations than success, but I've actually seen people lose 50-100+ pounds. I guess they really wanted surgery. So many people are telling them its not their fault or they have no control. They go to the gym 6 days a week, etc..."theres no workout you cant out eat". Weight is 100% diet, the gym is for fitness and recommended but a different purpose. People also use the gym as a reward system, 10 mins on elliptical and hit the buffet.

[SValleyMD]

Sorry had to laugh at the “upfront” with them comment..

Are you “upfront” with your junkies in the er?

It’s the most sensitive subject I come across

I can’t tell you how many pissed off pts I see that transfer to me from another provider and the first complaint they have is that “so and so just just said I was fat” or “so and so just blamed my weight. I’ve always been this weight”

You start being upfront and you will get lit up on your feedback. Now it’s awesome for those that don’t care or who can take the feedback abuse but for the others of us where that’s not possible you have to tread very very lightly

Now whether or not that is a disservice to the patient or not than I don’t know what to tell ya. Just the world we live in. Plus I have a hard time believing that a 300 lber doesn’t realize he should lose some weight.

I personally talk around the edges and emphasize increasing exercise as much as possible .. “your initial testing was normal, I do believe you’ll feel better by increasing your activity and exercise and losing a little extra weight, like all of us could benefit from. If that doesn’t work we can get more aggressive in the testing,. Do you feel comfortable if we try that first?”

Tough subject

[IntensiveCareBear]

Ever just tell them it is all about calories as you send them for a nutritionist/RD consult? There are a reason those RD new patients are usually hour long time slots; it is a concept that takes time to explain and outline. You are biting off more than you can chew trying to be a hero... and missing potential for referrals back from your local RDs! Even Endo don't do the vast majority of the weight management counseling and planning themselves since it just doesn't make time sense or financial sense.

We all know it is calories in and calories burned. It doesn't take inspiration, it takes dedication. Keto can work, WW (basically counting cals) works, high protein works, balanced works, South Beach works, DM diet works, Atkins works, MyFitnessPal calorie counter works, bla bla blaa...... all work as long as they get the balance right on calories. The other part of the equation is if the patients they actually stick with it, of course.

Most ppl are usually wanting easy answers that don't exist (vitamins or Adipex or secrets like certain foods or certain classes at the gym etc will make them skinnier), so let the RDs be the coach and bearers of bad news on this one. There are no easy answers, and fat people are fat because they eat too much for their activity level... not hypothyroid or slow metab or family genetics or bla bla. Kcal are a unit of energy, and it takes energy to maintain erect posture, beat the heart 70bpm, maintain body temp, etc. Basically any excuse they hope to find won't be there, so again, let the RD (or maybe an Endo) be the messenger on that. Some of the heffers will educate themselves and change their caloric ways (at least for awhile) and some won't, but you can do the right thing and stick to what is manageable.

Trying to do weight management as a PCP is like doing your own PT sessions or dialysis in the office. Refer it out. GL

Panscan wrote:

...Research shows that BMRs between normal people fluctuate up to like 300 calories a day, which is not the difference between between 300 lbs and 150(although people love to claim it is). I also think we vastly overestimate how many people have metabolic disorders which cause them to be obese.

Click to expand...

Oh for sure.^^ I was basically saying the same thing above. Given same/similar age, gender, and same weight, nearly any two ppl are virtually identical cal burn with same level of activity.

CordMcNally wrote:

A lot of these people just need their physician to be up front with them. You’re not going to make very many friends but you’ll change a few of their lives.

Click to expand...

Yes and no. While agree, I wouldn't be the one to be totally up front with them. The vast majority of them won't like the answer (and PCPs don't have time to give the whole answer/plan anyways)... so refer it. Nothing wrong with "Well, Jim, all of the of folks I have seen accomplish real weight loss success used calorie tracking systems. (hands Rx refer slip) It takes time to learn, but I know a few great dieticians who can really explain that well for you."

[MaxPower]

Isn’t the finance equivalent of this all the people that come on here, or Bogleheads, and say something to the effect of “We make 150k a year but just can’t seem to get ahead on our bills or save for retirement!!83!! We don’t spend any money on anything, eXcePT TAxeS...”

Then people ask for a detailed breakdown of their monthly expenses, and they look at it for the first time and it looks something like this:
$3000 per month house and second mortgage payment
$1500 food and eating out
$1800 day care
$900 car payments (but we need 2 new cars to drive to work!)
$ 300 for cable/internet/Netflix/cell phones
$ 300 utilities
$ 500 boat payment
$500 entertainment/vacations

But all of those expenses are sacred cows and can’t be touched for one reason or another.

The only way you can make this work (and I agree it’s probably not worth your time, which is unfortunate since being a proper weight minimizes or eliminates so many other problems), is to help them realize that they consume way too many calories for their sedentary lifestyle and job to support. I’m not saying it’s easy. I’m as guilty as anyone of having a long day of working my a** off standing in the OR doing hard cases all day then coming home and wanting to sit on the couch, watch tv, and eat a bag of Doritos. But the truth is you just can’t do that every day. For that reason I think an honest food diary is a great idea. Like with finances and budgeting and knowing where every single dollar goes, people have to realize, really comprehend, what they are eating, how much it is, and that there’s a problem.

People are tired from work and don’t have the energy to work out or be active. It’s hard. Getting started down that path is tough, and inertia is a powerful thing. I saw a study recently where they showed that young people who were encouraged to exercise or be more active started independently making better dietary choices. For me it’s because I realized how hard I had to work to burn the calories from that donut I just ate in the physicians’ lounge.

Not an easy answer. And there’s no magic bullet for it. I think you’re doing the right thing.

[Lordosis]

MPMD wrote:

 

You guys are dealing with HTN, HL, and DM up to your eyeballs to say nothing of smoking cessation, chronic pain, and that’s before we even talk about routine health maint. I have no idea how you would have time to create individualized weight loss plans.

Click to expand...

You got that right.  Our plates are full enough

ctt209 wrote:

Hi, first time poster, long time lurker on the forums (didn’t think my first post would be about medicine instead of finance!)

I’m primary care as well. What I’ve been doing with my patients is

First get a gauge of what kinds of diets they’ve been on before. Usually it’s some sorta fad diet/or crazy yoyo dieting or weird combo of “cleanses” and downing a bunch of apple cider vinegar. I do this 1) to get a rough understanding of the patient’s health literacy, and 2) make the pt feel as if they’re being heard and thus take whatever advice I give going forward more to heart.

I then ask them what their daily schedule/ routine is like, when they wake up and how many meals they eat etc, when they sleep, as I sometimes have a lot of night shift workers or truckers, and so giving them diet tips has to be somewhat grounded in reality/ limited by their work schedule.

Lastly, similar to you I do some calorie counting exercises with them. I first calculate their basal metabolic rate, to get a rough estimate of how many calories they need to eat to maintain their current body weight. I then tell them that healthy weight loss is losing 1 lb/week (not more than that). 1 lb of fat is roughly 3500 calories, so that means they have to be net negative 500 calories a day roughly. I then tell them to download either my fitness pal or lose it app on their phone and take a day or 2 and eat the way they normally do, except they have to log everything they eat, that way they get a rough estimate of how many calories they’re over eating. I then tell them to change the sequence of eating, as it takes 15-20 min lag time from when your stomach is full to when it sends the signal to your brain to stop eating. I tell ppl to get a large tub of spinach salad mix from Costco, cut up some carrots and cucumbers and eat it with hummus. When they first come home from work/ or feel ravenous, instead of binge eating chips/cookies, to eat the salad/veggies until they feel full. While they’re doing that I tell them to cook their protein (usually frozen salmon filet that I tell them to get from Costco as well), so by the time they’re full off the veggies, then the protein’s ready to eat and then I tell them to eat their carbs (breads/rice).

I then ask the pt to also try to incorporate some calisthenics/home exercise routine, even if for 10-15 3-5x/week somewhere during the course of their day.

 

That’s roughly the gist of it, and I send them to a nutritionist as well, and also screen them for OSA, as the vast majority of these ppl are gonna be positive for it.

Click to expand...

I agree and do much of what you do.  Glad to hear it though!  Welcome to the forum!

Zaphod wrote:

Drop the sugary drinks some.

Click to expand...

You cannot imagine how much sugar people can drink.  Even the diabetics.  Makes me sick.

SValleyMD wrote:

Sorry had to laugh at the “upfront” with them comment..

Are you “upfront” with your junkies in the er?

It’s the most sensitive subject I come across

I can’t tell you how many pissed off pts I see that transfer to me from another provider and the first complaint they have is that “so and so just just said I was fat” or “so and so just blamed my weight. I’ve always been this weight”

You start being upfront and you will get lit up on your feedback. Now it’s awesome for those that don’t care or who can take the feedback abuse but for the others of us where that’s not possible you have to tread very very lightly

Now whether or not that is a disservice to the patient or not than I don’t know what to tell ya. Just the world we live in. Plus I have a hard time believing that a 300 lber doesn’t realize he should lose some weight.

I personally talk around the edges and emphasize increasing exercise as much as possible .. “your initial testing was normal, I do believe you’ll feel better by increasing your activity and exercise and losing a little extra weight, like all of us could benefit from. If that doesn’t work we can get more aggressive in the testing,. Do you feel comfortable if we try that first?”

Tough subject

Click to expand...

I couldn't agree more.  I was just blasted on press ganey because I suggested that a patient's lower extremity edema might be related to his weight.  "My last doctor never mentioned my weight as an issue"  Well the guy was pushing 400lbs so that last doc did a disservice.

IntensiveCareBear wrote:

Ever just tell them it is all about calories as you send them for a nutritionist/RD consult?

Click to expand...

RD consults would be great.  None are covered by insurance in these parts for just obesity.  Only if you have DM.  Seems stupid but I do not make the rules.  So when people need to pay for something it rarely happens unless they are truly motivated.

[Lordosis]

MaxPower wrote:

Isn’t the finance equivalent of this all the people that come on here, or Bogleheads, and say something to the effect of “We make 150k a year but just can’t seem to get ahead on our bills or save for retirement!!83!! We don’t spend any money on anything, eXcePT TAxeS…”

Then people ask for a detailed breakdown of their monthly expenses, and they look at it for the first time and it looks something like this:
$3000 per month house and second mortgage payment
$1500 food and eating out
$1800 day care
$900 car payments (but we need 2 new cars to drive to work!)
$ 300 for cable/internet/Netflix/cell phones
$ 300 utilities
$ 500 boat payment
$500 entertainment/vacations

But all of those expenses are sacred cows and can’t be touched for one reason or another.

The only way you can make this work (and I agree it’s probably not worth your time, which is unfortunate since being a proper weight minimizes or eliminates so many other problems), is to help them realize that they consume way too many calories for their sedentary lifestyle and job to support. I’m not saying it’s easy. I’m as guilty as anyone of having a long day of working my a** off standing in the OR doing hard cases all day then coming home and wanting to sit on the couch, watch tv, and eat a bag of Doritos. But the truth is you just can’t do that every day. For that reason I think an honest food diary is a great idea. Like with finances and budgeting and knowing where every single dollar goes, people have to realize, really comprehend, what they are eating, how much it is, and that there’s a problem.

People are tired from work and don’t have the energy to work out or be active. It’s hard. Getting started down that path is tough, and inertia is a powerful thing. I saw a study recently where they showed that young people who were encouraged to exercise or be more active started independently making better dietary choices. For me it’s because I realized how hard I had to work to burn the calories from that donut I just ate in the physicians’ lounge.

Not an easy answer. And there’s no magic bullet for it. I think you’re doing the right thing.

Click to expand...

The similarities are impressive.

With finances and food we learn a lot from our upbringing.

I have my own bad excuses but I do not complain to my doctor to fix it because I know he cannot.

That is like taking your scenario to a financial advisor and hoping for some math magic.

Neither solution is complex.  Just hard implementing.