The medical establishment is ill-suited to deal with America's obesity epidemic

You did a write up on HBO's documentary "The Weight of the Nation" in which you called our obesity epidemic a wake up call for America ("Salad bars take root," May 1). Nothing new here. The alarm bells have been sounding for a while now.

I am an endocrinologist, and 90 percent of my patients are obese or near obese. This is a frustrating problem for doctors. There are no rewards for treating obesity.

It is well known among physicians that a diagnosis code of obesity on your insurance claim can get you rejected for payment. A lot of patients do not have coverage for obesity. Insurers will pay for hypertension, diabetes, osteoarthritis, heart attacks, sleep apnea, low testosterone, congestive heart failure and strokes — all consequences of obesity — but they won't pay for treating obesity itself.

The American medical system makes absolutely no sense. Obesity is a public health crisis, and the insurers have gone stingy on it. Even Medicare, which now boasts it will pay for obesity treatment, only pays for patients who are already obese. Prevention be damned.

Here's the rub: Obesity treatment is time consuming. Doctors have to take a thorough patient history, including a dietary history. They have to help patients make lifestyle changes. Those changes come in small increments and frequent visits may be necessary.

Meanwhile, the pharmacological choices for obesity treatment are limited and have many side effects. Medications are approved only for short-term use, and prolonged use is categorized as substandard care. Off label use of medications that help in obesity are frowned upon by the insurance establishment and the government as harmful, hence doctors are hesitant to use them.

Gastric by-pass surgery was until recently considered the treatment of last resort. Not anymore, however. It is now known that gastric by-pass surgery is a cure for Type 2 Diabetes and may be the best treatment of choice for the massively obese who have failed repeatedly with other treatments, dietary modifications and exercise.

But doctors still have to jump through many hurdles and complete loads of paper work to get this surgery for patients for whom it is indicated. And many employers provide insurance that excludes coverage for gastric by-pass.

Obesity is a complex chronic, recurrent and relapsing condition. Americans are told to make the right food choices and exercise. Yet, everyday they are bombarded with and tantalized by images, messages, recipe ideas and cheap foods that are detrimental to their health. Our societal cues are especially inimical to impressionable children.

We also imagine eating lots of vegetables and fruits will ameliorate the obesity epidemic. But eating too much of anything can lead to weight gain, and we are a nation of excess. We eat without thinking, and we live to eat. Even skinny people often eat too much.

We need to radically change our perspective and understand that obesity is a disease like diabetes, and that it requires lifelong treatment. But the American medical establishment is complacent, insurers are greedy and intransigent, and the government's public health campaigns are not reaching the patients who need help the most.

Usha Nellore, Bel Air

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