She just sat there and listened — what else could she do? Did he really think it was the first time she had heard this? Was the rehearsed monologue supposed to elicit some sort of epiphany? One of our pre-clinical instructors told us a story about how she went to the doctor’s office to get a refill, only to receive a 20-minute lecture about her weight by a resident. She walked out of the office both irritated and empty-handed, her refill not completed: “I know I need to lose weight!” But, at that juncture, and in that manner, she felt it simply was not the appropriate discussion.
As I listened to the story, I was horrified. That’s exactly what I do at my clinical visits … every time … with every patient. Though my patients were too kind to correct my misjudgment, I realized in retrospect that the discussion was probably not only unproductive, but also a reminder of an issue of which they were likely already aware. I always suggested diet and exercise, a mantra they had undoubtedly heard many times before, but did not think to ask or explore what prevented them from adhering to a regimen.
Obesity has always intrigued me. It seems like a pathology or addiction that would have a remarkably simple solution. All we need is diet and exercise, right? My father was an obesity researcher for many years at a pharmaceutical giant and was among the early batch of scientists to explore the potential of leptin, a hormone that curbs hunger, as a weight loss solution. They quickly realized that leptin served as a protective mechanism from starvation, not obesity. The hormone evolved to induce hunger in people with low body fat, not to curb hunger in people with too much. Continuing the family tradition, I looked at leptin levels in a population undergoing nutritional transition. They were high; the threshold of the hormones’ usefulness had been breached. Leptin’s inability to help our bodies stave off obesity is an elegant allegory for our inability to attack this problem. We have built an environment that makes it nearly impossible for humans to lose weight after they break a certain threshold. Our bodies are simply not wired to work at these new environmental frontiers.
As I attended each clinical visit with my preceptor on the south side of Chicago, I realized more than ever how complex is the issue of obesity and food addiction. Nearly every adult patient I saw was overweight or obese, which was not surprising in one of Chicago’s lowest income neighborhoods. Unlike other addictive substances like alcohol and tobacco, unhealthy foods are ubiquitously and inexpensively available in all neighborhoods, without age restriction. While an alcoholic can go cold turkey in the hopes of progressing towards freedom, a food addict does not have that option. Humans need food. People are now surrounded by an addicting substance necessary to survive with little alternative and can only hope that they can avoid the substance with self-discipline and internal motivation alone.
Ask any high school teacher what the most ubiquitously eaten snack in Chicago’s low-income communities is and the answer will almost always be the same: brightly red colored spicy chips. While teaching on the west side of Chicago, I often collected student papers smeared with the notorious red salt, and would catch students “red handed” as they snuck chips out of their pockets during class. While it is easy to criticize the students, or their parents, for a poor choice in snack, the reality is that in many poor neighborhoods, there are literally no alternatives. Some Chicago public school students would have to walk miles from school through dangerous neighborhoods to find fresh fruit or an actual grocery store, and when that becomes unreasonable, a salty alternative becomes the answer. Only after my clinic visits, when I saw the downstream consequences of these snacking habits, did I realize that the problem does not have a cross-sectional solution, but rather needs a long-term and comprehensive plan.
I don’t have a comprehensive solution, but I do have a better understanding of the problem. I won’t be giving patients 20-minute lectures on how important it is for them to lose weight on our first encounter; that discussion requires a relationship. I won’t suggest they buy alternative and more expensive foods outside of their budget and believe I’ve accomplished something. I will, however, be more acutely aware of how pervasive the problem of obesity is and I will continue to work towards understanding a solution in the future. Next time I encounter an obese patient, I won’t race to provide solutions, but rather seek to understand their roadblocks, and work with them to identify and deconstruct those, one by one.