Each week, many of my middle-aged patients ask me the question cited above. Obesity has become so commonplace in the United States that thin, healthy individuals are becoming the exception rather than the rule. With the rising prevalence and incidence of obesity in our society, patients have begun seeing this state of body habitus as the norm rather than the exception. “What’s the matter with being a little overweight, doc; everyone in my family is fat, so why not me?”
In response, I deliver my “fat” talk. In this sermonette on obesity, I stress the many increased health risks that overweight individuals incur: atherosclerosis, hypertension, gallstones, diabetes, colonic adenomas, degenerative joint disease, sleep apnea, deep venous thrombosis, and pulmonary embolism, among others. I try to communicate to my obese patients the importance of modest and gradual weight loss as compared with the cycle of rapid weight loss and equally rapid weight gain that is so common in our society. “Bouncing your weight up and down may even put you at greater risk for heart disease,” I continue, hoping that my message will take root in the patient’s mind. “Regular exercise such as daily walking is a great help in losing weight. Try to cut back on portion size, simple carbohydrates such as sugar and products made with white flour, as well as saturated fat in your diet. Would you like to speak with one of our dieticians?”
My daily preaching often goes unheeded and leads me and my internal medicine colleagues to become cynical about the possibility of ever convincing our patients to lose weight. This is, unfortunately, the price to be paid in a society that gratifies itself with every type of food taken in excess combined with widespread physical inactivity. Many of my patients ask about the surgical procedures that can lead to dramatic weight loss. I inform them that these operations carry risk and are really designed only for patients who are massively obese. Fortunately, most of my patients are only 30-50 pounds overweight and not massively obese.
Clinical science and epidemiology have convincingly shown that increasing body mass correlates well with rising blood pressure, lipid levels, and blood glucose, all important atherosclerotic risk factors. In general, the more obese the individual, the worse the combined burden of atherosclerotic risk factors. However, obesity alone is not a perfect predictor of atherosclerotic disease risk. For example, a number of epidemiological studies have shown that obesity alone is not a major predictor of coronary heart disease death once more prominent atherosclerotic risk factors that correlate with obesity have been removed. Thus, an obese person with normal values for blood pressure, serum lipids, and blood glucose is not at major risk for the development of atherosclerotic arterial disease. The most important issue to be considered in patients who are overweight is not weight per se, but rather the metabolic consequences of obesity.
As noted earlier, obese patients are at risk for many other health problems. Thus, an obese patient who is normotensive, normolipemic, and euglycemic might still develop severe, crippling degenerative arthritis or sleep apnea as a result of his/her adiposity. Consequently, physicians, including internists and other primary care providers, as well as specialists such as cardiologists, rheumatologists, endocrinologists, gastroenterologists, and other internal medicine specialists, need to look at the entire picture of a particular obese patient’s health and not just his/her risk for coronary artery disease. Indeed, physicians should not reassure obese patients about their future health if their atherosclerotic risk factors are normal, because other disease entities might come to plague such patients in the future.
It is important that modest weight loss in an obese patient with atherosclerotic risk factors can result in remarkable improvement in these risk factors. Indeed, it has often been observed that modest (~10% of body weight) loss of weight produces marked amelioration in elevated blood pressure, abnormal serum cholesterol, and glucose intolerance. Moreover, demanding that a patient try to reach his/her ideal body weight is often unrealistic and discourages compliance with the prescribed program of diet and exercise. In the end, “the enemy of good is perfect,” that is, we should strive to enlist our patients in a program that produces moderate, sustained weight loss rather than advising a draconian strategy that will almost certainly fail.
The National Task Force on the Prevention and Treatment of Obesity advises that the best strategy for weight loss is one of moderate caloric restriction, increased activity (that is, regular exercise), and a supportive program of behavioral modification to assist patients in remodeling their eating habits and style (1).
As always, I welcome your comments on our blog.
1) National Task Force on the Prevention and Treatment of Obesity. Dieting and the development of eating disorders in overweight and obese adults. Arch Intern Med. 2000;160:2581–2589.
— Joseph S. Alpert, MD, editor-in-chief
This article was originally published in the January 2010 issue of The American Journal of Medicine.
