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UAMS Weight Control Program patients Tim and Jody Ward ran in the “UAMS Better Fit 5K” in November. So far, Tim has lost 77 pounds and Jody has lost 63 pounds in the program.

The terms “lithe,” “svelte” and “fit” probably aren’t among the first to come to mind when thinking of Arkansans. Adult obesity is a massive problem in the state, and disagreements about treatments among weight-loss physicians are rampant.

Although a number of medical programs and initiatives are working to halt or reverse rising obesity rates, weight loss can be intimidating from a medical perspective as well as a personal one. Determining which of the countless and contradictory regimens to use can be as confusing for physicians as it is for patients. Setbacks are frequent, and patients can be hostile or evasive as they resist necessary changes. Even as physicians around the world decry obesity as the biggest public health crisis of the 21st century, data show that a great number of doctors are reluctant to take on their obese and overweight patients’ weight challenges.

Probably the most widely publicized weight program in Arkansas is at the University of Arkansas for Medical Sciences (UAMS), where Gov. Mike Huckabee lost over 100 pounds and transformed both his health and his political career.

Endocrinologist Vitaly Kantorovich is director of the UAMS Weight Control Program. He said obesity is long past being the uniquely American epidemic experts for years have been predicting. It has become a pandemic as less-developed countries around the world adopt first-world diets and habits.

“Even poor countries are obese,” Kantorovich said with incredulity in his voice. “India, for example, which was never, ever obese, ever, now has obesity rates that are mind-blowing. It’s going to get worse.”

A French study of 168,000 people in 63 countries published in the November 2007 issue of the Journal of the American Heart Association found that between 50 and 66 percent of the world’s population is either overweight or obese, with a quarter of the world’s population in the highest weight category.

Forbes reports that costs associated with obesity annually add $93 billion to the nation’s medical bill. The Centers for Disease Control said that each year, 112,000 Americans die from obesity-related causes, though other estimates are much higher. The condition is responsible for an increased risk of chronic diseases like type 2 diabetes, cancer and heart disease.

Kantorovich expressed frustration that while on one hand, physicians, scientists and the media are bemoaning the rising obesity rates, society continues to promote overeating in subtle, insidious ways, such as gradually increasing portion sizes. “For ages, 500 years, a nine-inch plate was okay with everyone.

Now, suddenly, plates are 14 inches,” he said. Thus, people habitually eat 25 percent more food. “It’s very dissociated; it’s a culture that cannot understand what it does to itself,” he said.

Another problem Kantorovich cited is the search for a quick fix. “We like shortcuts. We like surgery. What’s easier than liposuction? What’s easier than connecting your esophagus to your anus? You’re probably going to have horrible complications, but who cares? You’re going to be beautiful,” Kantorovich said sardonically. Although surgery can have benefits, too many bariatric surgeons pay too little attention to the metabolic trauma that surgery can cause the body, he said. The rigorous attention of an expert endocrinologist is necessary to interpret a patient’s specific pre-surgery needs and post-surgical follow-up.

The UAMS program gets impressive results, Kantorovich said, but it’s no quick fix. It consists of a multidisciplinary approach of a balanced, low-fat diet and nutritional supplements during the first 24 weeks, as well as behavior modification and exercise, with an emphasis on close medical supervision and extensive support for long-term weight maintenance. Patients see their endocrinologist weekly, and the customized treatment regimen gets regular tweaks as the patient’s body changes. Some patients need to lose only a small amount, but Kantorovich said weight loss of 100, 200 or even 300 pounds is not uncommon for the morbidly obese.

Diabetic patients drastically reduce their insulin dosages, sometimes completely, and frequently patients are able to get off all or most of their medications for other disorders that were caused or complicated by their obesity.

Although the program at UAMS is the best known, a number of other hospitals and healthcare facilities around the state offer successful physician-monitored weight loss programs following various regimens. Internal medicine specialists and family practice doctors also frequently treat patients for obesity, though reluctance to take on the frustrating challenge of managing patients’ weight loss is not uncommon.

“Nobody wants to be known as ‘the Fat Doctor’ per se,” said El Dorado physician Robert Watson II. “The majority of physicians don’t want to mess with it.”

Watson, a family practice physician, is one of the only physicians in the state who is board-certified in bariatric medicine. He said he treats at least 1,000 patients from South Arkansas for weight loss and maintenance, about a third of his practice.

Watson said Arkansas physicians as a whole aren’t yet prepared for the obesity epidemic. Previous generations of doctors tended to think of obese patients as lazy, and in some corners, that thinking persists. And even though current medications for obesity have been around for 20 years with no major side effects, he said many physicians remain wary of them.

Dr. Jeffrey Tate of Tate Healthcare in Rogers agrees about the stigma surrounding bariatrics. He’s treated 3,500 patients for weight management in the past nine years and says although he feels that his reputation as a respected professional in northwest Arkansas is finally solidifying, that’s not necessarily true for the rest of the profession.

“I think there is still an aura of charlatanism within the medical community, that physicians who treat obesity are passing out dangerous or ineffective treatments, promising patients results that are not really possible,” he said.

“Even for credentialed bariatric physicians, I think there’s a sense that it’s a sort of a sham, you’re taking advantage of desperate people. That’s going to take awhile to change.”

But Tate views the obesity problem and the solution differently. A psychiatrist by training, Tate began working on weight management with obese and overweight patients after a low-carb protocol helped him lose and keep off the weight he’d struggled with since childhood. He studied the literature, attended relevant medical conferences and began using his findings to help his obese and overweight patients achieve similar results. He gradually began to see obesity and its treatment through the lens of substance abuse.

Tate said he uses established addiction recovery psychology methods to help patients become successfully recovering carb addicts. He doesn’t consider it weight loss, per se. “My patients do lose weight, but the way they do it is to start recovering from their substance abuse problem,” Tate explained. “Their particular substance abuse is food, specifically either sugary foods or starchy foods.”

Tate tells his patients that like recovering alcoholics, even when they reach their goal weight, they are still recovering carb addicts. For many patients, particularly those with lifelong or severe weight issues, this may mean near or complete abstinence from sugary and starchy foods. “Unless they’re vigilant, the addiction cravings can come back almost immediately, and they can start to relapse very quickly,” he said. “I’ve done that myself. I’ve had to learn that even though I haven’t had a weight problem in eight and a half years, I’m still basically the same carb addict I ever was, and I could get hooked on pounder bags of M&M’s very quickly if I let myself.”

He recommends at least light exercise and half an hour of strength training twice a week to improve insulin sensitivity, and he prescribes medication as needed for cravings, insulin sensitivity and to help with emotions.

Kantorovich said treating all obesity as substance addiction is oversimplifying things. “Yes, there are a lot of people who are addicted to food or to their lifestyle. There are people who overeat because that’s the culture. You cannot say everybody’s addicted. I speak with each person, and they tell me what it is for them, tell me how it happened.” For example, a young woman with several children may need help losing her pregnancy weight, he said, but it doesn’t mean she has a food addiction.

Tate has a theory that as smoking became less fashionable 40 years ago, society shifted its tobacco addiction to the increasingly prevalent sugary and starchy foods. He said the data support these trends almost exactly. “We’ve seen a decline in smoking in the past 40 years and a tremendous increase in diets made up of sugars and starches and an accompanying increase in obesity. Although let me emphasize I’m not advocating that we go back to smoking,” Tate added with a laugh.

For Watson, weight management is a simpler formula of an appropriate caloric intake of healthy foods combined with regular exercise. Although the UAMS diet calls for fewer initial calories than Watson recommends, he and Kantorovich agree on the importance of making patients aware of just how many calories they consume in a week. “I always make them write down their calories for one week and add it up, and they see that they’re way above what they need,” Watson said. People underestimate how much they eat by 30-40 percent. “They’re astounded when they realize how many calories are sneaking in,” he said.

He informs his patients it only take 100 calories over what they burn in a day to put on 10-15 pounds in a year.

There are other vital components to lasting weight loss, said Little Rock psychologist Jan Dean. She works with patients who have all manner of food issues, from anorexia to obesity, and has recently started getting referrals from the UAMS Weight Control Program for patients struggling with their weight loss. “The emotional component is so important,” Dean said. “I do think physicians might start thinking of psychology as a really good avenue to help overweight and obese people. Psychologists and nutritionists can be a great help. It’s not strictly a medical thing. If it was as simple as just diet, people wouldn’t have weight problems.”

Regardless of the approach used to lose weight, keeping it off is a continual challenge. In the highly contentious field of bariatrics, physicians in all camps almost universally agree on this one point: no program can be successful if the patients do not make permanent lifestyle changes. Kantorovich said this point is so important, it’s the first thing he tells every new patient, and he continues to emphasize it through the UAMS program’s 24 weeks of behavior modification classes. Tate also offers a long-term follow-through with his patients, and Watson continues to see his patients monthly.

Tate advises physicians to expect people to have several attempts at losing weight. “Expect this to have the course of treatment that almost all addiction patients have. They start, they try, they relapse, they try again, they relapse, they try again,” Tate said. He also advocates having patients in counseling with someone who has experience counseling substance abuse patients and who is open to the idea of using their techniques with food addicts.

Kantorovich said that although physicians are pressed for time in working with obese patients, sometimes the most compelling thing they can say takes very little time at all. “We have numbers. People who lose weight will live longer,” said Kantorvoich. “The point to convey is not just quality [of life] talks, the point now is quantity talks. You’re not exaggerating, you’re not lying, just telling them, ‘These are your options.’ Everyone wants to live longer, get to see their grandkids. They will work with you. Just be persuasive.”



January 2008

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