My wheelhouse is preventative care, such as metabolic syndrome, obesity, wellness, nutrition, and movement. Obesity is a topic that is difficult for primary care physicians to discuss with patients, including obesity itself, preventative treatment, or lifestyle modification. We have to get more comfortable just even bringing up the conversation.
One thing I always try to discuss with a new patient is diet and exercise. I have posters and handouts visible throughout my office, and this allows a person to say, “I'm trying to lose weight,” or “I'd love to discuss this.” And that's honestly a big opening for an internist.
If I'm seeing 16 patients in a day, I probably had this conversation with 10. Because I keep the handouts so visible, patients will just pick it up, and they'll say, “Oh, can I take this with me?” And I'll say, “Absolutely take it with you.” And it opens up the conversation for us to have the lifestyle discussion.
Another thing is I always have visible is a version of the Healthy Plate. I'll introduce the Healthy Plate as a 10-inch plate; that automatically reduces the portion size, since the average American plate is 12 inches. Half the plate is nonstarchy vegetables, maybe some fruit if a person isn't insulin resistant. A quarter of the plate is lean protein. The final quarter is whole-grain carbohydrates.
It's easier to focus more on the quick intervention of 10-inch Healthy Plate, because digging into the individualized right number of calories can take a while. For those so inclined, here are a couple of simplified ways to recommend caloric decrease. If the patient weighs more than 250 pounds, limit their diet to 1,700 calories. For patients 200 to 250 pounds, limit the diet to around 1,600 calories. For patients 171 to 200 pounds, limit the diet to 1,500 calories. For 170 pounds or less, limit the diet to 1,200 calories. A second way is simpler—1,600 to 1,800 calories for men, or 1,400 to 1,600 calories for women. I've used both ways.
Obesity is important because we're giving medications for diabetes, we're giving medications for hypertension, but obesity itself is its own disease process, so I that should be addressed medically, and we should begin with diet interventions. We want to start having these conversations honestly, before you even see a patient become overweight. If I see weight going upward—a patient gained 10 pounds in six months—that's something that I want to discuss. “Hey, what are we doing with diet? Are we staying active?” If I see a patient with a BMI of 27, and they've got multiple comorbidities, that is something that actually qualifies them for medication. … It is a time to discuss, what are they eating? How are they moving? You want to encourage them to get back to a healthier way of living.
We have to get more comfortable with the conversation because the patients feel that discomfort. And so the more that you talk about it, and the more that you just incorporate it—you just have this handout, you have it as a part of your history taking—the more that you become comfortable, the more comfortable the patient feels talking about it. That is a nonjudgmental space. It really should be about encouraging them to be healthier.