Physician obesity: the tipping point.

As I bike through the early morning streets of Boston, my mind is awake, and my body feels strong. Ahead, I see the hospital where I work. Its pedestrian bridge spans a large urban street, and the brick of this building is deeply familiar to me as it has surrounded and greeted me on countless mornings and nights—first through my residency and now during my time as an attending physician. Already my mind has started to drift from the morning race of getting my three children to school to the dozens of chronically ill patients on my schedule, the medical students and residents with whom I have the good fortune to be teaching, and the multiple calls and meetings in the course of the day. All thoughts stop in the next moment when I feel a gale-like wind tipping my bike and with it, me, over. Fear washes over me. And then, as quickly as it had surged up, the gale force passes, and I am left unharmed. Looking up, I see a city bus filled with passengers (likely some are even my patients) unaware of their proximity to my relatively fragile bike and body. And as the bus continues its rumble down the street, all I can see is a comically outsized picture of a double cheeseburger plastered on its back.

Advertisements for such poor-quality, high-calorie food are all too familiar, and as a nation, we have witnessed the devastation of such food. According to a recent Gallup poll, the adult obesity rate in the United States has reached 37.2%, a significant increase from the year before across all demographic and socioeconomic groups.[1] This rate is consistent with childhood obesity, as one of every three children (31.7%) aged 2 to 19 years is overweight or obese.[2] Though many nations are catching up to the United States' unenviable numbers all too quickly (and Mexico has recently surpassed us), the US rates of obesity hover far above most every other nation worldwide.

As physicians, we are taught well the burden of chronic illness that obesity brings, including, among others, diabetes, cardiac disease, chronic pain, depression, and increased risk of cancer. As the Affordable Care Act and large private philanthropic efforts have now turned toward funding creative ways to reduce the burden of obesity in the United States, hospitals and clinics around the country are taking note and implementing more changes for patient counseling and programs.[2]

However, what is not often discussed is the burden of physician obesity in the United States and the role it will play in the future of our country's health. According to the 2007 Physicians Health Study, 40% of the 19 000 doctors were overweight and 23% were obese.[3] While physicians are less likely than average Americans to be overweight or obese, they are not immune to our national obesogenic tendencies. Indeed, as a medical oncologist at the Mayo Clinic in Rochester, Minnesota, Edward Creagan, MD, so aptly put it, “More of us commit suicide with a fork than any other instrument.”[3] Physician obesity rates likely have radically important implications.

In fact, it turns out that a physician's body mass index may be strongly associated with how he or she counsels patients about obesity. While normal-weight doctors and obese physicians are equally effective in diagnosing obesity in their patients, normal-weight doctors are significantly more likely to counsel their obese patients about weight loss.[4] Overweight and obese physicians report significantly less confidence than their normal-weight colleagues in giving their patients diet or exercise counseling.[4] Furthermore, overweight and obese physicians report that they are concerned that patients do not trust weight loss advice coming from them (based on the old adage, “Do as I say, not as I do”), whereas normal weight physicians are more confident that their advice makes an impact and that they can be models for weight-related behaviors.[4]

These findings imply that physicians and healthcare providers are more likely to provide nutrition and weight loss counseling to patients in ways more congruent with their own life experiences rather than through their medical education. Indeed, the dearth of high-quality nutritional education for medical students has been highlighted in recent years. Though the National Academy of Sciences published a seminal study on the importance of nutritional education in medical school and recommended nearly 30 years ago that a minimum of 25 hours of instruction be set aside for this subject alone, medical schools are still falling far short of this 25-hour low-bar minimum.[5] Moreover, little education is reserved for teaching effective behavioral change strategies such as motivational interviewing or group visits.[6] All of this occurs despite the mounting knowledge that nutrition is a cornerstone in reducing the burden of illness that is plaguing our country.

What is lacking in the medical classroom is also lacking on medical plates. Foods served at medical conferences and grand rounds are infamously unhealthy (for an exception, see Sidebar). In a recent JAMA article, the authors painstakingly calculated the number of meals served to medical physicians in the course of 1 year (2010): 40 000 accredited continued medical education events in the United States (all serving food), 9000 residency programs that serve at least one “free lunch” per week, weekly medical student free pizza club meetings at 125 accredited medical schools, and lunches provided to more than 46 000 applicants to residency and fellowship each year.[7] The same article goes on to argue that foods served at medical meetings do not adhere to any nutritional guidelines—a truth backed by further studies and one that many of us know all too well from seeking healthful food options at medical conferences. In a national survey of planners for medical conferences around the country, 92% cited cost as the driving factor for what goes into the meal, 100% responded that for each lunch and dinner, a dessert had been included and that all lunches offered included potato chips, snack mixes, or candy. One hundred percent of respondents offered soda at each break.[8]

Add to this deficiency the rigors of medical school and residency that leave learners with mountains of stress and debt but very little encouragement and incentive to get active, make basic healthful meals, or get more than 6 hours of sleep a night. Once learners finish their medical training, the ingrained habits of fast food and lack of sleep and exercise often do not abate. A recent survey done in nearly 2000 physicians practicing in California showed that 34% got 6 hours or less of sleep daily, 27% report “never” or only occasionally eating breakfast, and up to 35% of participants get very little or “no” exercise.[9]

As a country, we are at a tipping point. The devastating effects of obesity and its downstream consequences are leaving us economically and physically impoverished. Individual behaviors and health choices are often most affected by personal relationships, including that with a trusted healthcare provider. Thus, if we are to truly address the obesity epidemic in our country, the health and well-being of healthcare providers cannot be left out of the equation. In order for physicians to effectively counsel on health, they must, in some form, be models or at least espouse models of better health. Healthcare providers cannot do this alone.

We need true change in medical school education, residency, and beyond. Within the walls of the classroom, nutrition and behavioral change counseling must be placed squarely back into the cornerstone of health and medicine and given adequate time in the curriculum. There needs to be a radical change in incentives throughout medical training where medical trainees and trainers are given accolades for sleep, exercise, and balance. Low-quality foods served at hospitals and health centers throughout the country need to be replaced by fresh, nutritious, and living foods—foods that are a true representation of the health that we motivate our patients toward.

Good Food = Good Conference

Jennifer Blair, LAc

The American Holistic Medical Association (AHMA) got a chance to walk its talk at its September 2014 annual conference in Minneapolis, Minnesota. The setting was the Commons Hotel, a mid-sized contemporary venue located on the campus of the University of Minnesota, and food was the centerpiece.

Frankly, it wouldn't fit our image to have our speakers touting the principles of holism from the podium while attendees munched on junk food and sipped water out of plastic bottles.

We wanted our participants to feel nourished and able to remain engaged throughout the conference. No food comas from calorie-dense food! We wanted them to enjoy breaks and meals with a sense of community that would encourage dialogue, and we wanted the food we served to represent our principles.

Food preferences were surveyed at registration and demonstrated a healthy percentage of vegan, vegetarian, and gluten-free diners. It was important to us that attendees be able to share a table and a meal without anyone feeling they missed out or felt singled out because of a dietary need.

We asked the hotel to partner with us to create a food program that was local, seasonal, plant-based, and community-focused. The sales staff, banquet staff, and Executive Chef Bruno Oakman took on the challenge and did so with a flair that won them a standing ovation at our Friday lunch and rave reviews throughout the conference.

We asked that all meals be served family style, and we asked that everyone walk away from the table feeling nourished, regardless of their unique dietary needs. With these things in mind, conversation and interaction at the table became part of the dynamic of mealtime. People felt included and honored at every level.

Animal protein was served in smaller portions—a whole fish at the table served 8 people and helped attendees identify both where their food came from and the impact of their dietary footprint. Printed table menus recognized the local farmers who helped make each meal possible. Vegetables ruled at mealtime, and there was always a vegetarian protein option. A variety of grains were included in the menus, minimizing the need for wheat-free and gluten-free options.

Water was served at stations and infused with a daily delight such as local melons or cucumber and mint. Nobody missed the orange juice at breakfast or soda pop at lunch. Vitamix (Vitamix Corp, Cleveland, Ohio) was on hand to deliver a healthy afternoon treat.

Breakfast was designed to sustain the brain throughout the morning sessions. Organic, local, hardboiled eggs; fresh sliced tomatoes; chai-roasted delicata squash; fresh zucchini bread; and quinoa-millet porridge with crystallized ginger and almonds were among the daily options, alongside bowls of fresh local apples served with sunflower butter. Breakfast was replenished through the morning breaks to accommodate schedules and grazing.

The conference education included a live cooking demonstration. The lunch that followed featured recipes prepared by our faculty, which included Olivia (“Liv”) Wu, executive chef at Google (Mountain View, California). Chefs Bruno and Liv worked in partnership, and we all benefited.

We gave the hotel a modest daily budget and asked the staff to distribute the costs as they saw fit. Most days this included breakfast, breaks, a family-style lunch, and hors d'oeuvres in the late afternoon. In the end, the hotel staff was as delighted as we were and will carry forward what they learned as they consider how local, healthful, and holistic can become part of a marketing strategy to future conference planners.

The reviews reflected our success with phrases like “the best meal I've had in months” and “best conference food ever.” As we looked around at all the smiling faces, drinking in every moment of the conference, we couldn't help but notice what our grandmothers always knew: If you want to bring people together in harmony, first feed them well.

Jennifer Blair is a licensed acupuncturist who serves on the Board of Trustees for the American Holistic Medical Association and the Academy of Integrative Health and Medicine. She was honored to be part of the fabulous team that put together this year's annual AHMA conference in Minnesota.

Sample Breakfast Menu

Quinoa/millet congee with cashews, chili paste, crystallized ginger, raw ginger, coconut sugar, pickled vegetables

Local, organic, hard-boiled eggs

Assorted breads with apple butter, sunflower butter and jam

Assorted fruit and vegetable smoothies

Platter of local tomatoes (gluten-free/vegan) with whipped goat cheese and fresh herbs

Local apples

Sample Lunch Menu

Kale salad with blueberries and walnuts (gluten-free/vegan)

Roasted local beets (gluten-free/vegan)

Goat cheese with honey

Wild rice salad (gluten-free/vegan)

Sweet potato and white bean stew (gluten-free/vegan)

Chow-chow relish (gluten-free/vegan)

If we continue down the same road, the health of our patients and their healthcare providers may be tipped over by larger societal forces, with grievous consequences for all.