from the Trenches

Don’t neglect referrals to weight specialists

Regarding your article, “The obesity epidemic” (February 25, 2013): A common complaint of my patients is, “Why didn't my family doctor tell me about you sooner?” I calm their anger and prevent them from suing their primary doctor for delayed referral. It is reasonable to refer to a specialist if everything you've tried isn't working or if the patient has a problem that you'd rather not manage.

Don't think you should refer only “extreme cases” to a specialist. If you have a patient whose heart problem warrants a specialist in your mind, then apply the same logic to a patient with a weight problem.

Thomas Marlowe, MD

Charlotte, North Carolina

Focus on helping large-sized patients

Regarding the article, "The obesity epidemic," the trend to obesity in the United States has leveled off over the past 14 years, since 1999. There is no "epidemic." The average weight of all developed countries has increased with better nutrition, as has the average height. 

Second, although correlations exist between obesity and certain health conditions, your article implies that obesity causes diabetes, cancer, hypertension, and heart disease. The Framingham Risk Score does not use obesity. You will recall that it uses cholesterol, blood pressure, sex, and age, not body mass index (BMI). 

Third, the healthiest BMI is actually 25 to 30. This statistic frequently is ignored because of cognitive dissonance. Many Americans, including physicians, simply want to believe that thinner is better, because in our culture, thinner is seen as more attractive. There is a range of healthy BMI that probably extends from 18 to 32, depending on the individual’s level of activity, body fat and muscle composition, and genetic background. 

Fourth, at least 30% of all people with BMI less than 25 are unhealthy. Being thin does not mean being healthy, just as fat does not mean being "morbid" automatically. 

Unfortunately, no good treatments for obesity exists, as Charles Cutter states. Only a small percentage of people can lose substantial amounts of weight by calorie restriction and keep it off for 5 years. Dieting tends to lead to weight cycling along with low self-esteem, discouragement, and shame, which then leads to more sedentary behavior. 

What can we do to truly help our large-sized patients and encourage them to come to us for medical care? Please, let's break the cycle of shame and focus on the positives.

Exercising leads to better health, at any size. Quitting smoking and not using mind-altering recreational substances to excess is vital. Most Americans could eat more healthfully and mindfully. Taking needed medications diligently, reducing stress, having hobbies that are creative and active, keeping regular doctor appointments-these behaviors lead to success in health for patients of all shapes, sizes, cultures, and ethnicities. This success then translates to our success in the economics of medicine and success in addressing the needs of our obese patients.

Lenny Husen, MD

Antioch, California

MOC criticisms timely
The criticism that Dean Heller, MD, raised against the maintenance of certification (MOC) exam in “MOC exam not based on clinical practice” (Talk Back, February 28) is timely.

Along with its cost, inconvenience, and punitive nature, the little correlation with actual clinical practice that MOC has makes it deserving of criticism. Heller’s voice is only one of thousands who feel the same.

Edward Volpintesta, MD
Bethel, Connecticut