Despite the growing obesity epidemic, some physicians find it difficult to talk to heavy patients about their weight -- and even harder to help them lose weight.
A patient's weight is often the elephant in the examining room. Both patient and doctor know it's a problem, but often neither party wants to talk about it, says internist William Bestermann Jr., 62, medical director of a cardiovascular treatment program for the Holston Medical Group in Kingsport, Tenn.
But "if doctors are serious about keeping patients from having heart attacks and strokes, they have to have this conversation, and they have to help their patients lose weight," he says.
Bestermann is helping develop recommendations for physicians on how to guide and treat overweight patients on a committee for the STOP Obesity Alliance, a coalition of professional groups, businesses, unions, insurers and health care providers whose goal is to figure out how to best attack obesity.
"He has been a phenomenal advocate to convince patients and physicians that they are a team attacking this problem together," says Christine Ferguson, director of the alliance.
Debra Horne, 52, of Dungannon, Va., says Bestermann "gave me my life back" by addressing her weight.
In July 2007, she went to see him for the first time. "I'll never forget that day," she says. "Dr. Bestermann walked into the examining room and sat down and introduced himself. He said, 'I see you have a lot of medical problems,' but he never mentioned my weight."
At the time, Horne, who is 5-foot-9, weighed 298 pounds and had type 2 diabetes, high blood pressure, high cholesterol and high triglycerides. She had suffered from depression. She had had foot and back surgeries and was getting around on a motorized scooter. When she got down on the floor to play with her grandchildren, she couldn't get back up on her own.
Bestermann asked Horne to read The South Beach Diet. "He said: 'I'm not asking you to go on a diet or lose weight. I just want you to get the knowledge that is in there,' " she says.
The next time she went to see him, he had results of her blood work. He told her, "Debra, you are a walking time bomb, but I'm here to help you, and we're going to work on this together."
Horne changed the way she was eating. She stopped drinking four 16-ounce bottles of Pepsi a day and cut out fast food, ice cream, potato chips and most other processed foods. She started eating fresh vegetables, fruit, chicken and fish.
She saw Bestermann once a month for more than a year. She dropped to 149 pounds over time and shrank from a size 28 to a size 8. She went from taking 16 prescription pills a day to six. She no longer has to get around on a scooter; she is able to walk 2 miles a day with her husband and can get down on the ground and play with her grandchildren.
High cost of obesity
As the debate continues on health care reform, medical experts believe primary-care physicians need to launch a full-fledged attack against obesity because it cuts years off people's lives, reduces their quality of life and accounts for billions of extra dollars in health expenses. A study released this summer showed that obese Americans, those who are 30 or more pounds over a healthy weight, cost the country an estimated $147 billion in weight-related medical bills in 2008, double the amount a decade ago.
One reason for the high price tag: About 34% of adults -- more than 72 million -- in the USA are obese, which increases the risk of heart disease, type 2 diabetes, sleep apnea, several types of cancer and other diseases.
Bestermann decided he wanted to help patients trim down and get healthier after spending the first half of his career "signing death certificates and putting people in the hospital" because they had had heart attacks and strokes.
Most of his patients are obese and have weight-related illnesses. But when a heavy patient comes in for an appointment, he doesn't use the words "fat," "obese" or "morbidly obese."
"Most overweight patients know they should lose weight," he says. "Many want to lose weight. Most want to feel better, be healthier and be around for their grandchildren."
He isn't critical of patients' weight, partially because he struggles with it himself.
"I don't believe for a minute that they are weak or gluttonous or afflicted with a defect in character," says Bestermann, who once weighed 307 pounds but lost 45 pounds and has maintained the loss by cutting down on sugary and processed foods and saturated fat. He is 6-foot-1. "I'm always struggling with my weight. I need to be thinner than I am. I have more work to do."
The majority of his patients understand that their health and diet are tied together, but they are in the "wilderness" when it comes to figuring out how to deal with the problem. He advises them to aim for a weight loss of 5% to 10%, which has been shown to improve health. "I tell them: 'Let's not shoot for getting back into a bikini. Let's shoot for getting you healthier.' "
Specific steps
Bestermann has his patients watch a slide show that outlines the connection between diet and clogged arteries, and he recommends they read The South Beach Diet by cardiologist Arthur Agatston.
He suggests they allow themselves occasional treats so they don't feel deprived, but he also tells them what a wise doctor once told him: "There is nothing we can do for diabetes that you can't outrun with a spoon."
Physical activity is also key. "Every step they take, every move they make is tremendously helpful."
He doesn't prescribe any of the diet medications on the market because the weight loss with them is modest, and his patients do well with diet and exercise, he says.
At every visit, Bestermann reviews patients' weight and other medical markers. Sometimes fine-tuning prescriptions can help patients lose weight. After a few months, most of his patients have dropped 8 to 9 pounds, which is often enough to improve their health.
Sharing knowledge
Bestermann says not everyone who comes to see him succeeds at losing weight -- or even tries. "We do have people who will look you in the eye and say: 'I'm not going to do that. I'm not going to be bothered with that.' "
He spends up to 45 minutes with patients at the first meeting but less time after that, and this extra guidance comes at a price. He says his medical group "has spent hundreds of thousands of dollars" on the program to get it started. "Now we are seeing enough patients to generate the revenue we need, so we are getting close to self-sustaining now."
He's trying to fine-tune his approach so it can be replicated by other primary-care doctors. "This is one of the great opportunities to really improve health and lower costs simultaneously."
Horne says Bestermann inspired her to shape up where other doctors had failed. Several had told her she was morbidly obese but didn't give her any specific advice. After the appointments, "I'd go home and eat a bowl of ice cream for comfort." But with Bestermann, she says, "there was kindness in his heart and caring. He didn't throw a bunch of diet sheets at me that said eat low-calorie, low-carb, low-fat."
Instead, she says, he gave her the knowledge and confidence to succeed.
"I owe him everything," she says. "I feel like I have been reborn."
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