What’s to blame for the obesity epidemic? [PODCAST]

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“Obesity is a topic that literally hits home for me.  For the past two years, the website WalletHub has voted the McAllen-Edinburg-Mission TX metroplex as the ‘fattest city in America.’  As a health care provider, this is deeply disturbing because it puts my community at high risk for a wide variety of health problems, including but not limited to coronary artery disease, diabetes, stroke, and several cancers such as liver, kidney, breast, endometrial, prostate, and colon.  Not surprisingly, we also rank third for the highest percentage of diabetic (type 2) adults.

In a local news article published just after our unceremonious coronation, city officials were quoted as saying that WalletHub’s findings were, ‘… extremely misleading about the actual activities and health and wellness and well-being of our community.’  I’ve seen all of the strides that this area has taken to make exercise more accessible, with increasing healthy food options, gyms seemingly everywhere, and miles of paved paths for running and biking.  Each city hosts a number of races yearly, including marathons.  We even live an hour from South Padre Island, where there’s a wide variety of water sports available to enjoy.  Yet, the fact remains that our obesity rates still rank at the very top in the country.  So, what’s to blame for this health epidemic?  The plate is full when it comes to contributors, but we are missing out on the main dish.”

Henry Herrera is a gastroenterologist.

He shares his story and discusses his KevinMD article, “What’s to blame for the obesity epidemic?”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Henry Herrera. He’s a gastroenterologist, and he wrote the KevinMD article “What’s to blame for the obesity epidemic?” That got 7,000 shares on social media, so it really resonated. So we’ll talk about that in a bit, but first, Henry, welcome to the show.

Henry Herrera: Thanks. I appreciate it. Thanks for having me on here.

Kevin Pho: All right. I was wondering if you could share your story and your journey to where you are today.

Henry Herrera: Yeah, thanks. So I’m originally from an area of Texas called the Rio Grande Valley, which is deep, deep South Texas. Most people think of South Texas as San Antonio and Houston both, so I’m about four hours or so south of San Antonio, and I actually live about 10 to 15 miles from the border of Mexico. So really, really deep south. I was raised in this area, in McAllen, Texas. I did my undergrad in this area, and I moved to Dallas to do my medical school at Southwestern. I did my residency at Southwestern in internal medicine, and then I did my fellowship in gastroenterology at Scott & White, which is in Temple, Texas, about an hour north of Austin or so.

Leaving Dallas, I actually thought that I was going to go right back to Dallas and practice there. But you start having kids, you raise a family, and things change. Once I lived in Temple, I kind of realized that my idea of what I wanted for my family and for my practice changed. I started talking to some gastroenterologists who were from my hometown, my own community, and it just felt like a perfect fit. So I’ve been at DHR Health Gastroenterology for four years now. I’ve been very happy taking care of people here in my community, and it’s just been great.

Kevin Pho: Fantastic. And how has the pandemic affected you and your practice?

Henry Herrera: Man, it’s been tough. In one sense, I could say that I’m fortunate and blessed that it hasn’t been hit to the extent that it’s been hit in other areas, the major metropolitan areas that we all know about, in New York City, and here in Texas, Houston and Dallas are starting to get affected. But beginning about mid- to late March is when we started to really feel the impact, and April was essentially dead here in the clinic. We’ve had to really make some changes in terms of how we approach the practice and how we see patients. We’ve trended over towards telemedicine. April and May were almost 100 percent telemedicine visits.

And as a gastroenterologist, a lot of our practice also depends on endoscopy, and that was pretty much nonexistent for about six weeks there. And it’s understandable. Nobody wanted to come out and take the risk of being infected and being in a health care setting. Nobody wanted to be closer or take the risk of getting the coronavirus. So for a while, we just did a lot of telemedicine visits and did consultations that way. But slowly, once we kind of reached that area where things were starting to seem like they were leveling off, patients started trickling in a little bit more. And here, the last week or so, things are kind of starting to slow down again.

I imagine it’s probably the same as it is with all the other practitioners throughout the country. It’s just kind of one of those things. There’s not a whole lot you can do about it. You can’t blame the patients for not wanting to come in and take the risk. So the best we can do is try to offer the best advice that we can, either on the phone or when they come in person, and just respect their decision to want to stay home.

Kevin Pho: So let’s get to your article. You wrote the article “What’s to blame for the obesity epidemic?” Now, you practice near McAllen, Texas, and that city jumped into the public consciousness from Atul Gawande’s New Yorker article back in 2009, where it was the most expensive city for medical care before the Affordable Care Act. And reading your article, it was also named the fattest city in America, according to WalletHub. Now, that’s a lot to overcome. So what’s it really like to practice near McAllen, Texas?

Henry Herrera: So part of the reason that I wrote the article was, in a way, because of that article written by Dr. Gawande. It’s funny, a lot of the reason that we kind of make it into the public eye is for all the wrong reasons. Back then, it was for Medicare, and now it’s this obesity pandemic, and then here recently, we had this issue with chainsaw incidents. But one of the reasons I wanted to just make it known is to basically show that there are certainly things that we need to fix here in this area, but I also wanted to write an article and just show that there are some positives here in the region.

And I kind of wanted to make a point to say that, yes, although WalletHub did name us the fattest city in America, we’re not alone in it. It’s a universal issue, not just in South Texas, not just in Texas, but in the country. And so I wanted to make a point when I wrote it that, yeah, you kind of have to own it, right? We definitely have a lot of obesity in the area, and it contributes to a lot of medical problems that we have here.

I’m not a dietitian or nutritionist, but as a gastroenterologist, a lot of the disease states that I see go hand in hand with diet. You talk about things as benign as acid reflux and gastritis, but then you think about things like symptomatic gallbladder disease, you think about pancreatitis, you think about even things like diarrhea, constipation, and irritable bowel syndrome. You name it, almost every single disease process that I see in clinic, diet plays a role, a major role. And so I thought it was important to raise awareness about obesity in this area.

I think it’s interesting that in the U.S., as well as here in the Valley, people have made strides to try to figure out what we can do to improve on the rates of obesity. Every couple of weeks, it seems there’s a new diet trend, different exercise equipment. There’s CrossFit here, everywhere. There are gyms everywhere. Pretty much every block, you have something that you can do in terms of trying to improve your fitness. But yet we’re seeing every year that the obesity rate continues to increase. So there’s something that we’re not quite hitting.

And I kind of think that part of it is just the things that you do behind closed doors, the things that you do when you’re by yourself. They really play a huge role. I touched on it in the article. It’s going to the grocery store and, instead of trying to go around in the parking lot looking for that spot at the very front, maybe just parking in the back, and it’s an extra three or four hundred yards you have to walk each way. It’s taking the elevator as opposed to just walking up the stairs. Here at the hospital, I kind of have a general rule, and the fellows that I work with know that I’m not doing the elevator, man. I’m going up the stairs unless it’s four floors. That’s kind of my limit. I go up the stairs everywhere I go. And I think it’s important to do those small things.

I also talked about in the article that technology, to an extent, has been harming us, especially in this pandemic. I’ve got kids, and it’s hard. It’s hard not to feel guilty when your kids just want to be on the iPad all day, and you do what you can and try to get them out and exercise, but there’s only so much that can be done, especially during this time when we’re sheltering at home. But even during regular life, before this whole pandemic hit, I think a lot of people are spending time on their phones, on their iPads, on the computer, and not so much time just being outside.

Personally, I’m a huge outdoors person. I love being outside. I love jogging and exercising, those sorts of things. But I think you can only do so much in terms of creating restaurants that have healthy foods, and gyms. I think the onus is on the person to do all the little things to help lose weight, and I think every calorie counts. I think if you do that over a period of a week, a period of a month, and you’re consistent about it, I think the weight will improve. And with weight loss, you get improvements in all the other things that go along with it: hypertension, diabetes, risk of heart disease, risk of stroke, all these things that I kind of touched on in the article.

Kevin Pho: Everything you said, I see myself in my practice. I am an internal medicine physician. I have a primary care practice here in New Hampshire. Now, a lot of doctors are busy. We have a lot of bureaucratic requirements. Now we have all the issues related to the pandemic. What are some tips that you could share with your fellow clinicians on how we can counsel patients to address the obesity issue?

Henry Herrera: Yes. So I think that, as a clinician, one thing that I really wanted to make a point of here locally is that you have to approach it in kind of a multidisciplinary approach, I guess. So one thing that we did is we hired a GI dietitian to come on board with us. I’m not sure how your practice is; I’m sure you’re extremely busy. But for the most part, in private practice and even in academic medicine, it’s really difficult for one practitioner to talk about whatever the chief complaint may be and then also spend enough time, time that’s worthwhile, to speak about diet. Diet takes 30 to 60 minutes on its own.

And so one thing that I try to tell my patients is, “Listen, these are the issues that you’re coming in with. These are the things that we’re going to do about it. But one thing that you may benefit from is a dietitian visit.” Another thing is making sure that if they have things like diabetes, we try to refer them to a diabetes center. I just think that it’s important to think about it as a multidisciplinary approach.

And the other thing that I always try to tell my patients is to really try to break it down. I feel like every patient has their knack, or their vice. Some people at home, they’re just sitting around, and they decide, “Well, let me just go grab a bag of chips,” or “I’ll just go grab a cookie.” And then an hour later, “I’m just going to grab another cookie.” Well, at the end of the day, you’ve eaten five or six cookies. Or some people think that drinking sports drinks, Gatorade, Powerade, that those things are healthy, because they see on the commercials that all the athletes are drinking Powerade, but they’re not doing the exercise needed to burn the calories.

And so it’s explaining to them, “What is it? What’s your knack? Is it sodas? Is it chips? Is it snacking?” There’s always something. And so once I find out what that something is, I tell them, “OK, look, let’s look this up.” And sometimes I’ll grab my phone and I’ll say, “Look, I’m Googling this. A can of Coke is 150 calories. How many Cokes do you drink?” “Well, Doc, I drink a Coke a day.” “OK, a Coke a day, that’s 150 calories. You multiply that by seven, that’s about, what are we talking about, a thousand calories. You do that times a month, that’s, what, 4,000 calories. That’s about a pound.”

And so you kind of try to break it down into those very simple concepts and say, “Look, man, you don’t have to do a whole lot. I’m not asking you to exercise two hours a day. All I’m asking you is to just avoid that Coke once a day and do everything else the same, and we’ll see how you’ve done.” And if they’ve lost that 1 or 2 pounds, then I think you’ve gained their respect, and you’ve kind of gained their trust, and they’re saying, “OK, well, it’s not that hard to lose a little bit of weight.”

And a lot of these patients, NASH, for example, fatty liver disease, just a 5 percent weight loss will dramatically reduce their liver enzymes. You lose 10 percent, you can reduce and regress their level of fibrosis. So a lot of these things can go a long way, and again, it’s all the minor things. So I guess the take-home would just be, don’t focus on any major things. Focus on just the small details, things that seem like they would be simple for the patient to do. And I think that would make the patient feel like it’s not something that’s kind of an insurmountable, impossible task.

Kevin Pho: Well, thank you for sharing that advice. Now, Dr. Gawande wrote that article about McAllen back in 2009. Have things improved over the intervening 11 years?

Henry Herrera: Yeah. So what’s funny is he mentioned a couple of different hospitals that are here, and I think the hospitals that you mentioned are both still here. I do think that things have changed. Again, I’m speaking from being here for four years as a professional. When I lived here when I was younger, I don’t know that I really paid much attention to the way the health care system was. But I will say that one of the things that’s changed here is that we now have a university that has a medical school and a residency program, and here recently, we now have a gastroenterology fellowship. And I think that that’s changed the culture here in the Valley quite a bit.

Now, that’s actually another topic that I was thinking about writing about. I think it goes back to the whole idea that the Valley tends to be in the public spotlight for all the wrong reasons, but yet there’s not a whole lot talked about how the culture is changing here in the Valley. We have a primarily Hispanic population, but now we have medical students, we have residents, we have fellows, we have all these specialists that are coming in, and that’s really changing the face of this area. So I think that with practitioners and physicians that come from different parts of the country, you have different ways to practice medicine.

And so that type of management that Dr. Gawande alluded to back then, which included a lot of kind of overuse of labs and overuse of imaging to make a profit, I think all that’s changing. I personally don’t see that, certainly not within our group, and I don’t think that I see that as a whole in our hospital. I think things have changed. DHR Health is affiliated with UTRGV, and so we have all our residents, we have all our fellows, and med students rounding. And so it’s nice to see that this hospital has turned into a true academic institution.

Kevin Pho: My final question: What’s your take-home message for the KevinMD audience?

Henry Herrera: So what I would say to take home from all this is, obviously, obesity is a major issue. Right now, everybody’s so focused on the pandemic, the coronavirus. Then we have this whole social injustice thing that’s going on, obviously incredibly major issues that need to be addressed. But underlying all this stuff, we have obesity, and obesity can either get worse or better. We are stuck at home. You can either make those minor changes, or you tend to be more sedentary and things continue to progress.

So I guess what I would say is focus on the small things that you can do. Kind of take a look at yourself and look at your day and be honest with yourself and say, “OK, do I necessarily need to use the motorized wheelchair at the grocery store? Do I necessarily need to park at the very front? Do I really have to take the elevator? Can I take the stairs?” It’s those very minor things that make a huge change at the end of the day.

Kevin Pho: Wonderful. Thank you so much for sharing your insight. On the show, we have Henry Herrera. He’s a gastroenterologist. He wrote the KevinMD article “What’s to blame for the obesity epidemic?” Henry, thank you for joining me on the show.

Henry Herrera: Thanks, brother. Appreciate it.

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