Issue 4 / 6 February 2012

THE facts are in our faces. In the US, more than 35% of men and women are obese, while Australia rates fifth in the world obesity stakes.

As the US National Institutes of Health puts it: “Obesity and overweight substantially increase the risk of morbidity … Higher body weights are also associated with increases in all-cause mortality”.

What can be done?

TV programs show how people who are massively overweight may, quite appropriately, seek medical or surgical care with benefit. More frequently, though, the GP or specialist working in diabetes or heart disease will be treating patients who are overweight (body mass index 25‒29.9) or obese (BMI 29.9+).

Now a study from researchers at Johns Hopkins University in Baltimore has shown that doctors take overweight and obesity more seriously in their patients if they themselves have a BMI of less than 25. In the big picture of a society beset by overweight and obesity, where does this new piece of information fit? Does it matter?

Not much, is the answer. Genetic, epigenetic and environmental influences determine not only our weight but even our motivation to exercise and eat the right foods.

The most effective approach to obesity and overweight is prevention. Treatment is relatively ineffective especially when you ask: what effect did the treatment have after two years?

Cochrane reviews on the management of obesity and overweight are not encouraging. One assessed low glycaemic index or glycaemic load diets in overweight or obese people. It analysed six randomised controlled trials, involving 202 participants, with interventions ranging from 5 weeks to 6 months duration. Those on the low glycaemic index or load diet lost a mean of 1 kg more than those on comparison diets. So, some hope there even if only 1 kg.

Another looked at exercise. It concluded that “exercise has a positive effect on body weight and cardiovascular disease risk factors in people with overweight or obesity, particularly when combined with diet, and that exercise improves health even if no weight is lost”.

A review of “psychological interventions, particularly behavioural and cognitive-behavioural strategies … when combined with dietary and exercise strategies” was likewise mildly encouraging.

The outcomes for interventions in obese children are more positive. A review of 17 controlled intervention studies that involved primary care in the treatment of childhood overweight and obesity found 12 reported significant intervention effect, when assessed using a variety of outcome measures.

However, beware of overselling your wares to the overweight and obese. Suppose a patient who is overweight consults you because he or she is worried about a stroke. The message from published studies is this: be careful what you promise.

Cochrane again: “We were not able to identify any study of good quality investigating the relationship between weight reduction and the occurrence of strokes. If overweight or obese people want to reduce their risk profile by losing weight they need sound evidence for doing so since every intervention might have negative consequences as well, for example losing and regaining weight (“weight cycling”) is associated with health hazards like cardiovascular diseases.”

Overweight and obesity are environmental problems that require environmental changes to prevent and treat them as an excellent summary statement from the AMA explains.

Patients who are overweight who consult a chubby doctor who doesn’t fuss but discusses doable things, like GI diet and incidental exercise, might leave feeling better and behaving better than those seeing a thin doctor who reads them the riot act followed by lifestyle prescriptions that don’t work or are, frankly, dangerous.

Most of us want our human condition recognised — our flaws, failings, loves, hopes, aspirations, gripes, fears and even being chubby acknowledged.

If we can get that from a good GP, fat or thin, we are thrice blessed — whatever our weight.

Professor Stephen Leeder is the director of the Menzies Centre for Health Policy and professor of public health and community medicine at the University of Sydney.

Posted 6 February 2012

One thought on “Stephen Leeder: Good doctors come in all sizes

  1. JD says:

    A concise excellent summary on the State of the Art for non-surgical obesity treatment. Needs to be broadcast far and wide.
    The point about the detrimental effects of “weight-cycling” is important.
    However, I do tell patients if they’ve never had a decent attempt at weight loss, they might want to try, since 5% or so do succeed at long-term (> 2-5 years) weight loss maintenance.
    Otherwise, I tell them not to gain any more because they won’t lose it …

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