HAMPTON, N.H. — When Milton Martin Jr. decided he was past due to lose 30 pounds, the former body builder and college football player couldn’t bring himself to join a diet center.
“I don’t function well in group therapy,” he said, adding that he’d tried Weight Watchers and hated the meetings.
The 64-year-old accountant wanted more science and less socializing. He also wanted a plan that addressed all of his concerns — including his escalating cholesterol — not just his belly.
Now he sees Dr. Jennifer Warren, one of a small but growing number of physicians nationally who are specializing in weight management after their family practices were overwhelmed by patients with weight-related health problems.
'The ultimate preventive medicine'
“Primary care is preventive medicine. This really is the ultimate preventive medicine,” said Warren, who left her general practice in February to open Physicians Healthy Weight Center, a Hampton obesity clinic.
“That’s what got me started in this direction,” the 39-year-old said in a recent interview. “So many of the medical problems I was treating in family care were weight-related.”
Three weeks into his treatment, Martin’s cholesterol was down and he’d lost 12 pounds, thanks to low-dose appetite suppressants and calorie-cutting. And he doesn’t miss the meetings.
“If I’m going to lose weight, I’m not going to lose it for the group,” the Durham man said. “I’m going to lose it for me.”
With two-thirds of Americans now overweight and at greater risk for heart disease, diabetes and certain cancers, many in the medical community want to redefine the role doctors have in helping people slim down.
Doctors say the pressures of general practice — which can limit time with patients to mere minutes — and a lack of specialized training make it difficult to treat obesity in a primary care environment.
They say treatment involves not only creating individualized diet and fitness plans, but also assessing serious health concerns and addressing the underlying emotional and psychological issues that contributed to the weight gain.
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“In eight minutes you can’t undue all that stuff,” said Peter Vash, a Los Angeles doctor who has treated obesity for 25 years.
Though often associated with gastric surgery, a procedure that reduces the size of the stomach, so-called bariatric medicine includes a gamut of treatments, from special diets to counseling to prescription drugs.
The impetus for change comes mostly from medical schools, according to Dr. George Blackburn, associate director of Harvard Medical School’s nutrition division.
Medical students and young doctors are demanding to know more about nutrition and weight management, which previously was absent from most curricula, he said.
“We always ask physicians whether they see obese patients in the practice. They just laugh at us and say at least half,” said Beth Little, executive director of the American Society of Bariatric Physicians.
“They used to say there was nothing they could do,” she said. “Now they are just taking it a lot more seriously.”
Growing interest in field
Head counts of bariatric physicians are imprecise; the field isn’t tracked by the American Medical Association.
Little’s group has 1,104 members, an increase of 165 from two years ago. The American Board of Bariatric Medicine has 236 certified physicians, and expects to add another 50 this year. Most years the increase has been around 30.
There have been spikes before, fueled mostly by popular drugs and procedures, such as the now banned diet drug fen-phen and more recently a surge of interest in bariatric surgery. But Little said this time the interest is more sustained.
Academia has noticed. The theme of Harvard Medical School’s annual conference on obesity in June is “Obesity Medicine: Emergence of a New Discipline.”
Earlier this month, Duke University Medical Center announced it now will offer fourth-year medical students a course in the causes and treatment of obesity.
But change is slow. Though medical schools are improving at teaching nutrition, doctors complain that instruction still is limited mostly to postgraduate courses.
“When I came out of medical school in 1992, all we were told is tell your patients don’t eat fat,” Warren said.
Specialists struggle for respect
Until recently, the specialty struggled for respect. Vash, executive medical director at Lindora Medical Clinic in Los Angeles, said his decision to enter the field more than two decades ago mostly was derided by fellow doctors.
“Many of my colleagues looked at me and laughed,” he said. “Why would you go into treating obesity? That’s like the bottom of the barrel.”
It wasn’t until obesity was declared an epidemic some 20 years later that others took the field seriously, he said.
Money also is an issue. Though most insurers offer discounts for fitness and diet programs and cover nutrition services and even gastric surgery, coverage for services such as Warren’s is spotty, making it hard for doctors to get into the field.
Warren charges $95 for the first visit, which includes an exam, creating fitness and diet programs, and monitoring and treating any related health problems.
Monthly appointments thereafter are $75. Warren points out that her fees still are probably less than diet programs that require special food purchases.
Susan Pisano, spokeswoman for America’s Health Insurance Plans, a trade group, said this is an emerging field being studied by the industry. She noted that in 2002 a quarter of insurance plans included some kind of disease management plan for obesity.
Not very glamorous
Bariatrics also can be frustrating and not very glamorous. Treatment can take months or years, and its success depends as much on the patient’s motivation as the doctor’s intervention.
“It may not be as glamorous as a heart transplant or as rewarding as treating pneumonia and having the patient get better in a week, but it is very glamorous in the sense that you are giving this person a whole new orientation on life,” Vash said.
He also said the delay in recognizing the importance of bariatrics will prove troublesome for years to come.
“There are going to be so many patients coming to physicians for the treatment of their heart disease, and their diabetes, and their lipid problems and their back and knee pain that it has the potential to overwhelm our health care system,” he said.
Doctors in the field don’t consider themselves in competition with over-the-counter approaches, including popular diet centers such as Weight Watchers, saying people should use whatever method works for them.
But they say health concerns make them a better choice for many patients. Doctors also can enhance accountability.
“You’re really committing yourself when you’re going to a physician,” Little said. “If you don’t show up (at a diet center) nobody’s going to say, 'Oh, where are you?’ There’s a difference between that and missing a doctor’s appointment.”
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