Saturday, July 11, 2009


NewFNP is back from the most restful time she ever had in the state where she attended graduate school.  Her school years there were full of studying and bad weather and really bad weather, whereas her Independence Day long weekend was full of tranquility, mild weather and relaxation with grad school pals.  

And now she's back and has questioned more than once why on earth she lives in the urban jungle when tranquility and waterfalls are available to her??  Ah yes, proximity to Barney's.

Her first day back in clinic was also her first day with her second ever student from her alma mater.  It was a day filled with tough patients.

There was the 2-month old infant who would not make eye contact.  Is it a retinopathy? Is it an early indicator of autism?  NewFNP isn't sure.  Ophthalmology consult!  

Then there was the Mirena that twice fired prematurely with no assistance form newFNP.  NewFNP felt like a nervous lover - and in front of a student!  Eek.  Her student later asked newFNP if that was a normal amount of nervousness for an IUD insertion, to which newFNP replied, "For newFNP or for the patient??"

Then there was the 20-year old G1P0 who was far more interested in picking at her thick French tips than participating in her prenatal care.  

And finally there was the 19-year old G1P0 with a BMI of 55.5.  No joke.  She is 5-foot-1 and 294 pounds at 36 weeks gestation.  She was 254 at her first prenatal visit.  

NewFNP frequently reads lay articles and medical journals with stories and studies and statistics about the obesity epidemic.  Fourteen is the new ten.  Children are at risk.  This will be the first generation to die earlier than previous generations because of the effects of obesity.  The south is fat.  

OK.  NewFNP gets it - as a nation, we're fucking fat.  

But please, please.  Tell me just what in the world providers are to do?  These are the avenues newFNP has attempted with her portly nullip

1) just the facts, ma'am (health of mom and baby, labor complications, gestational diabetes risk); 
2) supportive listening and encouragement (yes, it's hard to change our habits but you're doing this for your baby and yourself; yes life has dealt you a rotten hand -- let's change that for you and your baby!!);
3) stern lecturer (this has to stop -  we are talking about the health of you and your child);
4) Richard Simmons (have you tried our prenatal yoga class??);
5) throwing the fruit punch in the trash.

And this is with one patient. 

Obesity is a public health problem.  This is not a problem that individual providers can address on a large enough scale to prevent and treat obesity.  It's not that newFNP doesn't talk to her patients about their weight - she does.  She talks to normal weight patients, underweight patients -- all 3 of them, and overweight patients about their weight.  But that isn't enough.

Children are fed trash in public schools.  WIC -- for all its great work -- gives away coupons for trashy foods.  Parents give in to children's pleas for junk food.  Poor urban areas are full of fast food options and liquor stores.  Poor urban areas are not safe for outdoor play and exercise.  Fruits and vegetables are expensive.  

So what are we going to do?   NewFNP is open to suggestions.  


Congratulations and love to BostonFNP and BostonJD.


Karen said...

That is a tough one... there are so many complications associated with obesity during pregnancy. Not to mention that she'll be in even more trouble next time she gets pregnant if she doesn't ever lose the weight gained this time around.

Way to talk to your patients though. That is really awesome. So many practitioners just sweep it under the rug for fear of offending folks.

BostonFNP said...

Much love to you as well, NewFNP. Couldn't have had a better time with you. Xo.

I totally agree with you about the scope and scale of the obesity problem. It feels completely insurmountable, especially when even the organizations that are supposed to help, like WIC, are part of the problem. Why do they give coupons for juice when kids turn 4 months old? It's really hard to tell a mother with few funds to ignore coupons for Juicy Juice, delicious as it is. Oh well, I guess I'll go ponder this over a bowl of ice cream.

Stephen Ferrara, NP said...

Hi newFNP,

While I agree that we must address obesity on a greater platform, we must begin with the one at a time approach. A lot of it comes down to education and recognition of these problems. I wonder how many other providers never mentioned weight issues to this patient. We can't give our patients a 1400 calorie hand out and expect them to follow it. Have we addressed the different cultural cuisines in these handouts? Not so much.

There is a lot we can't control - coverage of WIC items, higher prices of fruits/vegetables over happy meals, etc. But there is also things we can control. People won't change in 1 visit. It will take time but we can't give up. We need to know our communities where we pratice so that we can try and help steer our patients to healthier decisions.

Ok, stepping down from my soap box now.......

4elements said...

My day: room 60:468lbs
room 58: 350lbs
room 56: 350lbs
ICU. 2:3 new intubations. sadly, both did not sport Bariatric beds. only one "no-neck" got the camera scope intubation. The other was a struggle for 60 MINUTES!!!! remind me not to eat my Cheetos...

Anonymous said...

Of course.. its not the gov's job - nor should they delve into - feeding children. It will lead to dependency, waste, poor outcomes... no good can come of it aside from a given 'feel good' thought from those who hear about the plight of the hungry.
The more gov offers the more that will feel they need it.. and become less independent.

Anonymous said...

We need more dudes like Will Allen.