Ask Dr. Hallberg: Talking to your physician about your weight

When you go to your doctor's office for a routine visit, you'll usually get weighed in, and you might even have a conversation about weight loss — but how effective have primary care providers been in controlling obesity and its associated medical problems?

Two new studies in the New England Journal of Medicine, funded by the National Institutes of Health, shed new light on how successful primary care doctors have been in dealing with obesity and what might work better.

Dr. Jon Hallberg, MPR's regular medical analyst, discussed the studies with MPR's Tom Crann. Hallberg is a physician in family medicine at the University of Minnesota and director of the Mill City Clinic.

An edited transcript of that discussion is below.

Tom Crann: You're a primary care physician. Someone comes into a primary care clinic and they're overweight. How is obesity treated routinely?

Dr. Jon Hallberg: Well, we don't do a very good job. The studies show that less than half of us make some kind of comment about obesity. And fewer than one in four of us actually do something about it — make a referral or make a very specific recommendation. So we're not doing a very good job with this at all.

Crann: And what's the difficulty there in addressing it?

Hallberg: I think it's just so hard because obesity is so multi-factorial. A lot of it we perceive to be a lifestyle choice. Lifestyle choices are hard to address. We know that. And frankly I think it's easier sometimes just simply to not talk about it, and there's always something else. People are not coming in primarily to talk about their weight. It's something else, two or three other things, and it's just so much easier to focus on those.

Crann: And along comes the New England Journal of Medicine this issue with two new studies. What's new in these studies?

Hallberg: These are two very interesting studies, and these are two of the most promising studies we've seen lately. Both were studied, as you mentioned, by the N.I.H. They are under something called POWER or the Practice-based Opportunities for Weight Reduction consortium. So it's looking at different places around the country that are really trying to figure out what works.

And basically these two studies enrolled hundreds of people who are obese. These are not overweight people. These are people with obesity who have some heart disease risk, and they put them into kind of the gold standard trials, randomized control trials.

Crann: So according to these studies, what actually works?

Hallberg: Well, if we look at the similarities between the two studies, it looks like intense intervention, which could be either in-person or over the phone, works the best.

Crann: Now what does that mean, intense intervention? You're going to call patients up and say, 'Put down the ice cream?'

Hallberg: A little bit of that, actually. So what they found is that you'd have scheduled visits in the clinic. So for example, a person has diabetes. We want to see them probably two, three, four times a year. Well the same thing with this, regular visits. Every time they go in, their primary care physician would encourage them to be part of this study. Even if they're in the non-interventional arm of these studies, they'd encourage them to be a part of it. So they're getting that sort of verbal face-to-face encouragement.

There could be some group participation. There could be some other one-on-one meetings. They typically involve a lifestyle coach, somebody who either in-person or over the phone is giving them all kinds of information and tips and suggestions — frankly, in ways that we don't as primary care providers.

Crann: How effective is this level of intervention?

Hallberg: Well, one would think that it'd be really great, and again these are some of the most promising findings, but only one-third of people at the end of two years lost about five percent of their initial body weight. And that five percent is sort of a tipping point. If you can lose five percent, the thought goes that you reduce your heart disease risk and risk for other things like diabetes. That was the best, and it was about one-third.

Crann: And yet that's relatively promising?

Hallberg: It is. Anyone who knows smoking cessation rates, for example, it is such a difficult thing to do. Again, these lifestyle issues are so hard that that is actually considered quite promising.

Crann: So how is all of this likely to change the way you deal with obesity in the clinic?

Hallberg: Practically speaking, I don't know if it's going to. I think that it takes so much effort, and keep in mind that these studies were funded, and so this extra stuff that was done was paid for. The question now is: How do you extrapolate that into real life, real clinic situations? Who's going to pay for that? I think that's going to take sort of a top-down approach to make that happen. So the reality is I don't think a lot's going to change just yet.

Crann: In your experience as a primary care physician, is there something in common to the success stories, though, that you have seen in the clinic when it comes to people losing weight?

Hallberg: Well, I think on the one hand, if people are morbidly obese, they're just severely medically overweight to the point where it's causing all kinds of problems, I have to say that when people have had gastric bypass surgery, that that's one extreme example where I've seen success after success, but not always.

For people who are obese, at least based on their body mass index, that proportionality guide, I think that there's something that they have that people who are successful with it take it on as a task, a job. They become very focused on it. It's not something that happens by chance. They're using their iPhone apps and they're keeping track of their calories and they're working out and they're just taking it on. And they really have to. It's just not something that happens passively.

(Interview edited and transcribed by MPR reporter Madeleine Baran)

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