A HEALTHIER PRESCRIPTION
Not all physicians who treat fat people encourage them to diet, take pills, or have surgery. Like the physicians and weight loss surgeons at the bariatrics conference, Allen King, an endocrinologist in Salinas, California, has tried everything to help his patients lose weight. For 21 years, he treated thousands of obese and diabetic patients, three-fourths of them women, with very little success.
At first he put patients on standard calorie-counting diets. They generally lost weight quickly and gained it right back. Then he prescribed very low calorie protein powder shakes for more than 500 patients. “Our success rate would be fifty pounds lost in six-months,” says King, “and sixty pounds regained in three years.”
Next came the gastric balloon. King worked with a gastroenterologist who inserted the inflatable device, designed to make people feel full, into the stomachs of twelve patients who were markedly overweight. Some of them lost weight, but mainly because their abdominal pain was too intense to eat. Others experienced more extreme side effects: Five developed stomach ulcers, two had obstructed intestinal tracts, and one required emergency surgery to remove the balloon.
After that, King and an oral surgeon wired two obese patients’ jaws shut. “The patients started drinking high-calorie milkshakes,” says King. “They gained weight.” King then recommended even more radical surgery. First came the intestinal bypass; over half the patients developed kidney stones, arthritis, liver disease and other serious illnesses. Then came stomach stapling: Most of the patients would lose a third of their weight the first year, but it wouldn’t stay off. “After five years, the weight would return to where they began,” says King.
King finally came to the conclusion that there was nothing he could do to help his patients lose weight. Not only were the treatments unsuccessful — and risky — but they harmed his rapport with his patients. Ashamed of not sticking to their diets, they would miss appointments and fake their food diaries. They would binge and then fast like crazy before having to step on the doctor’s scale. They would diet to comply with doctor’s orders, and then, away from his watchful eye, go right back to their old ways. “I’m so tired of being ineffective as a physician,” says King.
He’s not the only one. In face of a trend to medicalize obesity, a few physicians are going in the opposite direction. As more physicians are finding out just how hard it is to help obese patients, some have begun to wonder whether diets are merely exercises in futility and a setup for defeat. Instead, they are trying new approaches to obesity which, unlike dieting, don’t make the problem worse. Some recommend no treatment, others much more moderate lifestyle changes. Wayne Callaway says obesity treatment needs to focus less on losing pounds and more on figuring out how the patient can gradually learn to live a more active, healthy life-style. For some, that might mean getting out and walking once a day. For others, it might mean therapy to root out underlying causes of overeating. For a few, it might mean medication. “It’s a much more complicated approach than putting people on thousand-calorie-a-day diets,” Callaway says. “I don’t see any reason to do that anymore.”
He says that physicians need better training to understand the limits of obesity treatment, as well as the complex reasons behind why people get fat. Obesity isn’t just a simple energy-in-energy-out equation, as many physicians still believe. It may be a genetic condition, a hormonal problem, a psychological problem, or a lowered energy requirement from long-term dieting. Callaway suggests that physicians who treat obesity need special postgraduate training in residency programs or at medical conferences in order to assess the genetic, emotional, motivation, and behavioral components of each case.
Allen King in Salinas has also adopted a new approach to helping his obese patients improve the quality of their lives. He and a nutritionist who works with him, Dana Armstrong, use a non-diet approach, and tell patients that they’re not going to restrict their diets. Basically, they don’t tell their patients what to eat, but leave that to them. They explain to patients what happens to their health when they eat too much fat and sugar, and ask them to notice the changes they feel in their bodies when they eat those foods. But they tell them to decide for themselves what to eat.
Their approach, called “demand feeding,” is similar to the techniques advocated by Geneen Roth, Overcoming Overeating, and other feminist anti-dieters. It asks that patients sort out their true hunger — the hollow, rumbling kind — from emotional hunger, which may arise from stress or habit. When patients give themselves permission to eat, and don’t feel deprived by a diet, says King, they’re less likely to overeat. The approach also gives the patient, rather than the physician, responsibility for taking care of her eating habits. “Patients become self-directed, and they make their own decisions about their bodies. After time, they usually make good decisions.”
Maren Martin, a 40-year old diabetic, came to see King after a long history of yo-yo dieting and wildly fluctuating blood sugar levels. “I would always diet well and lose weight,” she says. “But then I’d gain it back in a storm.” With Armstrong and King’s help, she gradually stopped dieting and started allowing herself to eat anything she wanted, making decisions based on when she was hungry. After two years, she no longer binges as she used to. “The foods that sparkled before because I couldn’t have them just don’t seem so special now,” she says. Martin’s weight and blood sugar levels have stabilized, though she is not thin.
After seven years of using this approach, King says he has finally succeeded in helping many of his patients stabilize their diabetes, sometimes lose a few pounds, and, most importantly, control their problems themselves. Unlike diets or surgery, King says his approach is no quick fix. It takes one to five years for patients to stop dieting, learn to eat what they want — and want what they know is best for their health.
“As a physician, you have to realize that you can’t treat a patient’s obesity,” says King. “All you can do is give her the information, skills, and confidence to do it herself.”
© Laura Fraser