Arya! Arya! Arya!

In Weight-Loss Maintenance on February 19, 2011 at 9:29 am

Let me start by saying I don’t agree 100% with everything on Dr. Arya Sharma’s blog.  For example, I think his Best Weight Practical Guide to Office Based Obesity Management (which he co-authored with the venerable Yoni Freedhoff and from which he regularly draws material for reposts) is a gross oversimplification of what is required of doctors and patients if they really want to have an impact on weight.  In this most recent repost, for example, he suggests

“. . . it is safe to assume that a patient who is unable to commit to 30 minutes per day of combined dietary and fitness effort will be unlikely to succeed with weight management using a purely behavioural strategy. Asking patients whether they feel they can find 30 minutes a day for their weight management effort will help to assess their readiness and willingness to change.”

To that I gasp, THIRTY MINUTES?!  No wonder the mythology persists that it’s all just a zippy “lifestyle” change, when our wise doctors promote this kind of crap.  Thirty minutes devoted to a less toxic diet and some exercise may marginally improve someone’s health, but it is nowhere near enough time to have ANY permanent impact on weight.  

On the other hand, the man, Arya, on another day can be brilliant.  I’ll say it:  genius.   For example, on Friday he talked about the complexity of calorie intake as related to weight.

Clearly, he respects his own field of specialization, and yet he has not dropped the notion that General Practitioners can and should press patients to manage their weight.  He is disappointed that they are “unenthusiastic,” but maybe he should hear that as a clarion call.  His Practical Guide presses GPs to make behavioral prescriptions in the name of weight management (as opposed to mere health improvement), but the GPs know, intuitively, that those prescriptions are hollow, at best.  They may even be damaging, because their dismal results can foster disillusionment and depression.  To my thinking, asking GPs to help their patients with weight management is ludicrous.  You might as well suggest that the GPs should be performing routine brain surgeries too.

Tomorrow or Monday, I will post my response to his brilliant Friday post.  I’m still letting it ruminate (ferment?).  How can I not adore him when he agonizes over weight issues as much as I do, and he applies his considerable training and expertise?  I bow to his dual doctorates.  His work, taken as a whole (and ignoring his simplistic “Practical” Guide), to me suggests a whole new model of medicine as it may apply to weight and health maintenance.

  1. I’m in his fan club. I’m in yours,too.
    Sometimes he writes things that I consider oversimplification, or even veering toward the insensitive, but I continue to think he is the best mind on this continent when it comes to weight-related stuff. He’s grounded in compassion, and can switch from the big picture to the patient in his office on a dime.
    You continue to rock.
    I eagerly await your ruminations.

    • By “best mind on this continent” I mean from a medical perspective. There are many great minds from the sociological, mental health, anthropological, and perspectives of many other disciplines. Just to clarify what I meant.

  2. Can’t wait to hear what you have to say about this article, which I read yesterday and which I referred to in a guest post that I hope will be published some time this coming week.

    I can only echo your initial comments (as those of Acceptance Woman). He’s only human, he’s far from perfect, but when he gets it right…WOW, you just want to trumpet his words from the rooftops.

  3. Thanks for the kind words. Not sure I agree with you that I’m “venerable”, but can assure you, whether you or others agree with my opinions or not, I speak from my heart.

    Content of our book aside, I want to comment on the 30 minutes note.

    Certainly I know how it was intended (as I believe I wrote that passage) – the 30 minimum minute was intended to help busy family physicians ascertain whether or not a patient’s state of change is one of readiness. Weight management efforts for many involve far more than 30 minutes but the point of the paragraph isn’t to suggest that 30 minutes is all that’s required but rather to suggest to the practitioner that if a patient isn’t willing and ready to put in a minimum of 30 minutes, that patient is likely looking for magic which as you well know, we sadly don’t have.

    • Dr. Freedhoff, welcome to DJM! I am the arbiter of adjectives ’round these parts and (today) you are venerable.

      I’ve bounced about Weighty Matters, love your fiesty opinions and have enjoyed myself a great deal at your Friday posts, but I cannot pretend to be a fan of the manual that you and Dr. Sharma have produced. It’s like providing GPs with a quarter dose of obesity antibiotic and turning them loose to treat. It may do more harm than good. Regarding the 30-minute rule, I don’t question that your heart is kind, but I stand by my original post: that advice re-enforces the cultural mythology that weight loss maintenance is about little changes (that create dramatic results). Your field is so littered with heartache — people failing to maintain hard-won losses and blaming themselves. A strong dose of truth would really be healing, and empowering. My opinion, from the heart. Feel free to visit any time, and definitely check back on Monday.

    • Am I allowed to humbly say that while I think Dr. Sharma is awesome, that Dr. Freedhoff is, too?
      I overall liked “Best Weight” as a primer, and that’s how I read it.
      But it didn’t include much in the way of the patient’s perspective.

      I’m a fan of MI, as it turns out, because I think it can prevent some of the feeling of persecution about weight that patients can feel — if someone says they aren’t ready (or interested), the provider is free to move on to pursue other paths. And the patient is still free to bring it up or be asked respectfully if they have changed their minds.

    • Dr Freedhoff,
      I hope you don’t make assumptions about people’s existing habits; I hope you ask about them before inserting the “half hour” thing. Otherwise, you’re likely to get a lot of dropped jaws and fed-up looks from patients like me.
      a fat lady who already exercises and cooks from scratch.

      • “Unemployed” so far has meant “lots more cooking from scratch” because I can trade time for money.

        Yet, contrary to popular expectations, I haven’t lost weight. Hm.

  4. First, Debra, thanks for your reassuring remarks directed towards my comment about my uncertainty re: “fitting in”! As usual you demonstrated kindness, empathy, and wisdom.

    I have not yet read Friday’s post to which you are referring here; however, based on Yoni Freedhoff’s comment above about “readiness” for change I am left WONDERING to what extent have health care professionals been influenced by the MI (motivational interviewing) model of “communication.”

    Here is a quick introductory link to the MI concept that seems quite representative of the MI model, which I was taught (in nursing school) to include among my tools when practicing McNursing (yes, ouch):

    There are aspects of MI which, superficially, resemble an improvement over more traditional *directive* models. Mainly there is more emphasis on creating (an illusion of) partnership rather than reinforcing hierarchy, but… there are still many assumptions about power and knowledge that remain uncritically examined by many (or most) practitioners who choose to *use* the MI model (*on* patients). Note, one cannot rightly say used *with* patients, given the fact that patients are left uninformed of the premises that are motivating the motivational interviewers’ behavior.

    The model retains many of the (inherently) oppressive constructs of Western medical culture. If one reads closely, and listens closely to the way MI is practiced, typically, the threads of domination are subtly woven throughout, and they provide much of the weight of the fabric(ated) rhetoric of empathy.

    This criticism is not directed against any practitioners, only against a model that may have been employed by ANY health care provider who believes people can be, umm, empowered to change with the right techniques.

    Believe it or not, that’s all I have to say on the subject for now. 🙂

    • Thanks for the link, RNegade. MI Sounds a little better than old fashioned condescension. Perhaps if doctors are motivated to use MI, then it shows the doctor’s “state of change is one of readiness,” and while MI is not all that is required to establish a doctor-patient health partnership (any more than 30 minutes total devoted to exercise and scratch cooking will result in weight loss maintenance) maybe it’s a first step, eh? If a doctor isn’t willing and ready to institute MI, at minimum, that doctor is likely looking for magic compliance, which as you well know, we patients sadly don’t supply. 🙂

      • Jesus. 30 minutes a day dedicated to exercise AND cooking from scratch? That’s nothing. I hope he asks people how much time they’re already spending – or does he just assume that people with high BMIs don’t cook or exercise?

        I already spend probably an hour a day, on average, cooking and (if you count walking) an average of 1/2 – 1 hour a day exercising. And, I’m in a new job, trying to maintain a web site, and doing some other volunteer work as well. In my own opinion, I’ve been neglecting my health lately.

    • Ha! Thanks RNegade. That really clarifies things. I realize after reading that that doctors have tried using motivational interviewing on me before. However, they tend to get derailed by the fact that I don’t give the answers or express the concerns that they’re fishing for. This explains why I have so many awkward conversations with doctors that end up with them trying (or not) to cover up their frustration.

      • Yeah, DeeLeigh, MI (and other health “management” models) are based on the assumption that a person has the ability to control (or *improve*) their weight status based on whether or not the person remains ambivalent about changing.

        Yet taking responsibility does not mean being able to control the outcome of one’s actions, it simply means being able to respond. Yes, we can respond (take action), but our actions may or may not result in the (patient’s or doctor’s) desired outcome. That illogic underscores the mythology behind all of Western medicine and nursing: humans can supposedly manipulate patient outcomes by taking the most effective steps. However, this mythology also supports several false beliefs, such as: 1) effectiveness can be measured by objective outcomes, 2) effectiveness is related to behaviors that can be rationalized, and 3) effectiveness in the short term indicates potential improvement in the long term.

        Argh. Does anyone else see the circular logic and magical thinking here?

      • Me too 😦

        Of course, often they skip the “Have you considered trying to lose weight?” and go to “You should start walking, say, 10 minutes a day and work up to 30 minutes a day.” Somehow “What makes you think I don’t?” isn’t the answer they’re looking for.

        On the other hand, my ARNP was impressed enough with my flexibility and lack of back pain to ask how I exercising, including the type of yoga I do. 😉

      • I don’t know what it is about nurse practitioners, but it seems they somehow end up embodying the best of medicine. I’ve only known a few, and mostly in social settings, but each one was a gem.

  5. I’m with DeeLeigh. That’s an average of 30 minutes a day, total, of cooking from scratch, food shopping, AND exercising? And they think no fat person already does that, and more?

    Not only am I already a confirmed pedestrian because I can’t drive (I know how, but would rather not maim anyone), but I HAVE to cook almost every lunch and dinner from scratch (and what the hell, I usually make enough for another meal, too) and spend incredible amounts of time sourcing and purchasing food because of my digestive issues. If it turns out I do have Crohn’s (for which I’m being worked up currently), it will probably have to go higher than that, even. Thirty minutes, my bounteous bottom.

    (Which is not to say that I blame anyone who can’t put that kind of time in or has other priorities. I’ve been there, believe me. People who already work like dogs — at whatever — should not be called “lazy”!)

    Dr. Sharma’s got some interesting things to say, but it seems like he talks out of both sides of his mouth. Is weight totally within an individual’s conscious control, always…or is it not?

  6. It takes a while of reading Dr. Sharma, Meowser, but I think he merely acknowledges that weight control is complex (before he publishes a book that insinuates that GPs, in their 15-minute appointments, can just help patients handle it in their spare time). I hesitate to put words in his mouth, but I think he would say some individuals can exert conscious control over their weight with some success, and I would stand as proof that he is right.

  7. I would add – GP’s should not be working with patients with any type of ‘balance’ meds for depression or chemical imbalance or the like. I feel very strongly we need to be checked by a psychiatrist and then if meds are needed, continue to be monitored by psychiatrist and not turned back over to GP.

    • @Vickie, unfortunately, in the real world of health care USA-style, the cost differential between having a GP manage one’s meds and having a psychiatrist manage one’s meds often represents the difference between being able to afford to take one’s psych meds and having to live (somehow) without them. If we are lucky we can afford McMedicine (better than nothing, maybe), if we are not lucky we go without, but if we are wealthy or have amazingly good health insurance coverage (rare), we might actually get most of the health care we need.

  8. RNegade,

    From your postings I’m led to assume that you’re not a fan of physicians or our respective medical systems.

    I’m also led to assume that you feel the medical system and society as a whole have failed the obese and that doctors (and perhaps everyone else) overgeneralize, oversimplify and all in all treat all those who struggle with their weight the same way, and in so doing are wronging a large percentage of the population.

    I think you call it, “McMedicine” to reflect the formulaic approach you believe physicians take with patients.

    Consequently I find it surprising that you seem comfortable expressing what seem to be McGeneralizations about the medical profession as a whole here, and while certainly mistreatment or exposure to an uncaring and/or uneducated medical system or practitioner/s may explain what to me reads like anger (maybe I’m misreading – certainly it’s often difficult to read the emotions of an online writer), I don’t think it justifies it.

    There are in fact wonderful physicians out there who care deeply about their patients and while far from infallible, certainly aren’t deserving of generalized derision.

    If I’m misreading your intent, I apologize, but that’s how it reads to me.

    Meowser and DebraSY – our book is meant as a bare minimum of knowledge for a physician who’s interested in learning more about the complexities of weight management. With time being at such a premium for everyone, we elected to write as concise a book as we could. Of course there’s a great deal more to teach and talk about, but we chose to err on the side of short so as to try to maximize the number of health care providers who actually set out to read this book during their likely scarce amount of free time, and at the very least, shock them out of the, “you should just eat less and move more” world of weight management.

    • Physicians, as individuals, are simply human beings schooled in a particular paradigm which, in the USA particularly, meshes quite neatly with the economic system of late capitalism, a system that is currently driven by the economic interests of mega banks, pharmaceutical corporations, oil companies, insurance corporations and so forth. Their lobbyists write our laws, for the most part nowadays, and innocent people suffer, including innocent nurses and doctors.

      Individual health care providers are not the problem…in fact, my own GP has one of the kindest hearts I know, and he does what he can to practice ethically within a health care system that is broken and morally bankrupt. I especially admire him because he has testified in public and before the legislature on several occasions (such as on our local NPR station) about his concerns regarding patients who are waiting longer and longer for consultations and treatments (or are simply going without basic medical care) because their medical insurance is linked to their employment status or because they have inadequate coverage.

      In other words, somehow he has learned to see the human costs in the current system, he recognizes the terrible inequities and the suffering related to disparities, and he is actively engaged in the political process to try and improve it. His vision and activism come at a personal price to his well being. He is one of my heroes.

      Those professionals who cannot see the growing immorality of the current system (and who remain silent while the suffering of our fellow human beings increases) are tragic figures. They are not bad, they simply have not yet been exposed to the kinds of educational opportunities that would open up a paradigm shift within their lives. Or, I suppose, some have seen the layers of immorality and feel paralyzed or powerless to break free. They don’t understand the the complex ways in which their actions maintain and strengthen the status quo. In truth, I see them as victims of the system too. Their lives are diminished because they miss opportunities that could result in greater emancipation for themselves as well as for others.

      So, yes, I have a definite perspective. But it is not focused at the level of individual doctors and nurses, most of whom chose to pursue health care as a profession because they wanted to make a difference, they wanted to help others. My gaze is focused on the culture and on the power structures and the implicit communication theories that construct, repair, and maintain our sick society.

      • You know, RNegade, the more I read your writing, the more I think maybe you’ll be the one to write this generation’s medical version of The Jungle. (Then pray you’ll find a publisher.)

  9. “McMedicine” is RNegade’s term, not mine. I find it a bit harsh, and I don’t repeat it, but I allow free expression here. And I understand that as an RN in public health, she’s been “burned” by that system. I honor that.

    I see physicians in three-dimensions (I’ve had both good and bad experiences), but, yes, I do think the disease model of practice has not served fat people well, and probably most of the people participating here share that notion. I think you are, indeed, hearing anger. That’s accurate. We do expect more from doctors than what we get from cultural mythology, and we aren’t receiving it.

    I remain a fan of you and doctor Sharma, but not your manual. (See, I see you in more than one dimension.) I think your manual is too short. I think the system expects too much of GPs.

  10. To be honest, I’m glad my GP never says anything about my weight. She knows the medical trials and tribulations I’ve been through (and continue to experience) and I suspect she (rightly) believes that adding weight loss to the mix would just send me over the edge. She is always supportive of the sustained effort I make to stay as healthy as possible despite my limitations, and for that I am eternally grateful.

  11. Dr. Sharma, I really wish you’d comment on the issue of fat patients who already cook from scratch and exercise regularly. Don’t you think that maybe doctors should congratulate us on our good habits instead of pressuring us to spend even more time cooking and exercising?

  12. DebraSY, you’re of course entitled to your opinions. Lord knows I’m the last person who’d suggest you weren’t. All what a bonus that you are one of those sadly too rare individuals who are able to disagree without it becoming personal.

    DeeLeigh, I’m not sure who it is who told you that all there is to weight management is cooking from scratch and exercise. Certainly for many those would be remarkably good places to start, but as you note, for many others, they’re already foregone conclusions.

    Given that every person struggling to lose weight has different contributions – medical, genetic, behavioural, societal, and more, there is no prescriptive advice that fits each and every person. That said, if a person’s current lifestyle has them in an equilibrium weight wise, clearly something will need to change to affect energy balance and more often than not, that’ll require an investment in time to learn, plan, monitor and support a new strategy or approach.

    Of course there’s also the real possibility that the person in question has already reached what Arya and I refer to as their, “best weight”, which would reflect their weight living the healthiest lives that they can honestly enjoy. Were that the case, and if that person had no medical or quality of life issues as a consequence of their weight, there weight would not only be their best weight, I think it’d be a great weight for them and perhaps the only thing left to do would be for their physician to ensure there were no iatrogenic issues that they, their physician, could modify.

    I would also point out that your generalization, that all us doctors are going to pressure you to spend more time cooking and exercising and not congratulate you on your good habits is no more fair than a doctor generalizing that all patients with weight to lose don’t cook from scratch or exercise.

    • Sorry about that generalization, but it’s been my repeated experience with doctors, all of the 35 years I’ve been fat. And actually, they pressure me to diet; to take on a restricted eating plan. If they were pressuring me to cook from scratch and exercise (I got that from your blog, actually), then I’d be happier. That’s better advice, IMHO, although I do already do those things. Yo-yo dieting has caused 4 of my aunts and uncles to put on 100+ pounds each over the years. I won’t do it, and the fact that doctors are still recommending the same thing to me today – 30 years after this bad advice was given to my parents’ generation – really makes it hard for me to respect them.

  13. For what it’s worth, I just started a modest program to lose weight, aiming for about 1 pound per week. I spend about 50 minutes a day walking (2 25-minute miles) 30-45 minutes cooking a tasty and healthy dinner, and 10 minutes updating my progress spreadsheets. That’s 10 to 11 hours per week to lose one pound. If I make it to my goal of 200 pounds, a BMI of 34.3, I will have invested over 400 hours in the project. Then I will probably spend at least that amount of time on an ongoing basis maintaining that weight, or maybe more if my body is stubborn and wants to go back.

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