Published Articles

This quote emphasizes the basic premise in preventive health care– that food is a drug. In fact, it’s one of the most powerful drugs that we put in our bodies. Yet it is the drug that is most casually dealt with. It is a pleasurable drug, a social drug, and a drug we cannot live without.

Proper nutrition is essential to the wellness of our patients, yet the knowledge of nutrition is left to the dieticians or the veterinarians. The closest physicians get to nutritional training is how to order TPN, or whatever fad diet we’ve tried to tackle our own battle of the bulge. This hardly prepares us to teach out patients the basics on maximizing the benefits that can be obtained through optimal nutrition.

With obesity being out most prevalent nutritional imbalance, our most common nutritional counseling centers around assisting our patients to lose weight. We no longer have the luxury of telling our patients “eat less and exercise more”. Similar advise would be to tell an asthmatic to “breath deeper”. I’m sure most of our patients would be eternally grateful for such profound advise! No wonder they turn to fad diets that only lessen the weight of their wallet and can adversely affect their health.

The research in the treatment of obesity is enjoying a recent renaissance; none too late with obesity at endemic levels, affecting 34%of our population. Missouri ranks second in the incidence of obesity (Indiana ranks #1). Obesity also has huge financial impacts on our society. Six percent of our health care dollars go to the direct cost of treating obesity-related problems. According to the information from one NHANES III, 66% of obese patients have at least one co-morbidity, and 27% have two of these co-morbid conditions– hyper cholesterol, diabetes, or hypertension.

Excessive weight should be viewed as a symptom, similar to how we view a patient with a cough. The differential diagnosis could range from sinus drainage to pneumonia to carcinoma. I challenge you to view obesity in the same manner. Dig deep for contributing factors– insulin resistance, polycystic ovarian syndrome, depression, physical restrictions, genetic or seasonal influences, hormonal imbalances, or iatrogenic causes? If this is a specialty of medicine you don’t feel comfortable with, refer.

Individuals who struggle with weight problems are the last type of people who will be able to just do without food. They tend to look at food very passionately. Food serves various purposes in their lives. Basic nutrition guidelines to reduce weight need to be taught in a very user friendly manner.

Their nutritional education needs to be monitored to assure that it is successful, appropriate, and livable. Food journaling is one of the quickest ways for you to assess your patient’s knowledge and needs. At our clinic we initially use a Target approach (Table 1)

Table 1 (grams per day)	Women	Men
Fat	20-25 grams	25-30 grams
Protein	50-80 grams	60-90 grams
Carbohydrates	50-100 grams	75-125 grams

Counting calories alone is inadequate for proper nutrition. The target approach offers a more specific approach. Adequate protein intake (1 gram per kilogram of lean body mass) is required in order to avoid muscle loss. Calories from fat and carbohydrate are restricted to create an energy deficit. At first, patients may find this documentation cumbersome. Development of this skill is necessary for them to acquire lifestyle changes. Once they are comfortable with this skill, they are able to be creative with whatever food situation they face. We carefully review journals with patients. Much effort is made to analyze– not criticize- their log. If a patient were to keep a headache diary, you would use it to learn how to best intervene with appropriate treatment. A diet diary serves the same purpose, especially when using pharmaceutical interventions. Reviewing a journal can enable a physician to get the most out of the smallest dosage. Minimal dosing is critical because of the tolerance that develops with some obesity drugs.

Pharmaceutical treatment of obesity goes much further than signing a prescription. Tailoring of treatment regimens requires detailed assessment of individual needs. Often clinical trials are the most valuable deciding factor to determine the right pharmaceutical “cocktail”. Off label approaches are commonly used in the treatment of obesity. Double-blind studies document the effectiveness of nonconventional therapies. Skilled counselors and office staff are a must in the treatment of obesity. Comprehensive patient support, including, exercise training, stress management workshops, and cooking classes prove invaluable when treating the whole patient.

Assisting your patients to improve their nutrition and level of wellness is very rewarding. Not only are you treating a multitude of underlying health conditions, you are also empowering them with skills that can have huge impacts on not only how long they live, but also how alive they feel each and every day.

-Published in the March 2001 GCMS Bulletin