The Curbsiders on why they believe that primary care needs to own obesity management.
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Matthew F. Watto, MD: Welcome to The Curbsiders. I'm Dr Matthew Watto, here with my great friend and America's primary care physician, Dr Paul Nelson Williams. We have some pearls from a great podcast on obesity medicine, because this is a big part of what I talk about in clinic every day.
Paul N. Williams, MD: The number of patients who bring up the topic with me has increased exponentially, in part because we now have more effective treatments than we've ever had before. They broach the topic of medication management and changing their diets. It's a conversation I've had much more frequently in the past 5 years than I did when I was starting out. I'm not sure if that's because I'm better at talking about it or because patients are more likely to bring it up, or some combination of those things.
Watto: All my training in obesity medicine has been through our podcasts and then trying it out in clinic, because we weren't really taught about obesity in medical school. The big change since we graduated medical school was around 2013 when they started calling obesity a chronic disease. We have to think about it with a chronic disease model, like diabetes or high blood pressure.
Some patients who make major lifestyle changes can come off medications, but the majority of patients need some help, and medication might be part of that. This is one of my big soapboxes, Paul, and you know this. In primary care, we have to own this. This has to be something that we are good at treating because there's just not a "people board-certified in obesity medicine" to handle this. So, this is our world. Do you agree?
Williams: Yes, 100%. We should have familiarity with the medications anyway for other reasons, and motivational interviewing is well within our scope. We have all the tools at our disposal to address obesity as a chronic health issue, like we've been trained to do.
Watto: We will talk about some medication pearls, but I know you're a physical exam nerd. Let's say that my patient is really upset and saying, "I'm not losing weight. I'm working out. I'm eating right. I'm not losing weight." Can we show them something else on physical exam that is proving that things are getting better?
Williams: Or not! In a recent podcast, Dr Will Yancy talked about measuring waist circumference. His method isn't consistent with research methods, but that's not what we're talking about here. He measures waist circumference at the level of the umbilicus. Make sure that you have a nice long measuring tape because a standard measuring tape might not fit around the patient's waist. With a long measuring tape, you avoid making people feel defeated right out of the gate.
And it's hard to measure another person around the waist unless you're going to be hugging them, which is a weird thing to do. Rather than trying to reach around their body, Dr Yancy has the patient hold the measuring tape and sort of pirouette in a circle. You can easily grab the measurement as they circle around.
Watto: I love that. And if they're working out and starting to lose weight and eat better, they might be building muscle. So, their weight might be steady for a little while, but they might actually be losing inches, and that's a way to prove to them that they are making progress.
Paul, the reason so many patients are coming in and asking us about obesity treatment now is because it's in the news so much with the new medications. But I have a lot of patients come in and say, "You know what, I just can't take these medications. I'm nauseous, I'm constipated." How do we troubleshoot that?
Williams: It hasn't been an issue for me yet because I've not been able to get any of the medications through the pharmacy. But let's say that I am able to do so. There's a lot of anticipatory counseling around the medications that I probably should be doing. One of our experts talks about advising patients to halve their portion sizes immediately and not wait until they are feeling awful. People don't consciously think about their portion sizes unless you counsel them to do so. Whatever they normally eat, they should cut that in half to start out and see how they do. It gives them a chance to collaborate on their delayed gastric emptying and decreased motility, giving their bodies a chance to catch up.
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