Wednesday, July 20, 2011

Obesity, Alcohol, Tobacco, and Primary Care

I'm in Vermont, telecommuting and enjoying the Green Mountains while my wife teaches at the Bread Loaf School of English, a Middlebury College program in which students, mainly K-12 teachers, can get a Masters degree in the course of five summers.

Students and faculty have meals in a building that served as a summer Inn a century ago. Last night at dinner two faculty members I was sitting with began to talk about how many Weight Watcher "points" the different foods had. They graciously allowed me to grill them on their experience with weight management. Here's what I learned:

Neither had succeeded in maintaining weight loss on his own. While they did not care for the meetings associated with the Weight Watcher program, both found the weekly "check in" helpful. I probed.

Did they have an extended conversation with the person who weighed them? No.

Was it always the same person? Yes, usually. But they did not appear to find the relationship itself important. It was the public weighing that supported their motivation.

One of the two men followed the recommendation that he keep a daily log of what he ate. This made him more conscious of the act of eating. He'd ask himself - "do I really want to eat XYZ, or am I just on automatic pilot?"

Both had achieved and maintained significant weight loss. Their health (blood pressure, cholesterol) and energy had improved.

We shifted to smoking. One had smoked heavily while in graduate school. A group of friends vowed to quit, and promised to pay the others $50 each if they lapsed. My friend reported - "I was too cheap to pay out all that money, and I haven't smoked since."

I told them how medical education teaches us a lot about how to deal with the downstream wreckage caused by obesity, alcohol , and tobacco, but little about the upstream self-management approaches for prevention. In my own experience as a psychiatrist, I'd learned pathetically little about alcoholism in medical school and residency. Luckily, to prepare myself for teaching primary care and psychiatry residents, I'd gone to a number of AA meetings myself, and, with permission from the groups, took students to meetings. I was able to talk with patients about the embarrassment I'd felt when the receptionist at the entrance to a facility I visited to scope out a meeting asked me where I was going - sometimes it helped them with their own dis-ease about exploring AA.

Every time a patient mentioned an AA or NA meeting I'd get them to describe it. When and where did it meet? Who was the group best for? Who might be uncomfortable there? I'd write down the information and put it into a progressively larger file. Then when talking about AA or NA with patients I was encouraging to explore the program I took out the file and thumbed through it. My sense was that apart from the information it contained, the "evidence" of my serious interest in AA and NA, and the echo of the voices of other patients that came through my notes, often had power.

No companies monitor us for effective referrals to AA, NA, Weight Watchers and other support and self-management programs the way the pharmaceutical industry monitors our prescribing habits. There's no money in it and no high tech glamour.

All there is is the intrinsic satisfaction from helping people improve their capacity to promote their own health and well being!


Patrick Anderson said...

Our health care system at Chugachmiut will be integrating our primary care and behavioral health systems to help address the problems you identify. Our practice will be utilizing a tool developed at Kaiser Permanente in San Diego which they based on the results of their Adverse Childhood Experience Study (ACES) that demonstrated strong relationships between unresolved childhood trauma and negative behavioral responses and poor health outcomes later in life. Dr. Vincent Fellitti, co-PI for the ACES, commented about obesity and ACE's in this article:

Jim Sabin said...

Hello Patrick -

Thank you for introducing me to Chugachmiut and the Chugach region of Alaska. I'd heard about Dr. Fellitti's work but hadn't read any of his articles - thank you as well for the link.

I'm guessing that obesity is a significant problem among the native peoples Chugachmiut serves. I'll be very interested in how supplemented absolute fasting combined with a psychologically deep group support program work for your group. I'd encourage whoever is responsible for the program to keep good data on it, and ultimately to write up the experience the way Dr. Felletti did.

I don't know if fasting is part of any native tribal traditions, but as I read Dr. Felletti's description of the program, I was struck with how "religious-like" it is: fasting combined with probing of the private places of the soul!

I hope I can visit the Chugach region some time in the future - I've never been to Alaska.



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