Initiating Honest Conversations About Obesity
by Rynae Golke
According to several studies (including the Behavioral Risk Factor Surveillance System and the National Health and Nutrition Examination), more than two-thirds of patients can be classified as overweight or obese. Because patients who are overweight are at higher risk of chronic diseases that decrease life expectancy, weight screening and counseling are an important part of the primary care doctor’s role.
However, according to one study published in the Journal of Clinical Outcomes Management, only 18% of obese patients received counseling on weight loss from their primary care provider. Additionally, according to a study published in the Journal of General Internal Medicine, only 61% of patients agree with their provider’s notes regarding the discussion of weight, physical activity, and diet during their appointment. This means one of two things:
- providers are often documenting that weight, physical activity, and diet were discussed when they were not discussed, or
- providers are discussing weight, physical activity, and diet but not effectively communicating in a way the patient understands
What barriers make discussing diet, physical activity, and weight with patients so challenging? There are many barriers that might prevent or impact the discussion.
- Doctors like to present problems and solutions together, but many doctors don’t know what to tell patients about losing weight. As a matter of fact, most doctors are not trained in weight management or nutrition. Of those who did receive related training in medical school, only 23% consider it “quality” training.
- Doctors don’t have time to talk to patients about the solution. Even when doctors know what the patient can do, walking him or her through a lifestyle change takes much more time than prescribing Metformin for obesity-related type 2 diabetes. The next patient is waiting.
- Doctors believe they will not be reimbursed for obesity screening and counseling.
- With two-thirds of Americans falling into the overweight or obese categories on the BMI scale, there’s no doubt that some doctors are overweight too. Doctors who are overweight may feel uncomfortable counseling patients who are overweight.
- Doctors fear confrontation, being “fired” by a patient, and/or experiencing negative word of mouth when a patient is offended by the discussion.
Primary care providers can improve their skills in the weight management portion of their responsibility by taking steps to gain knowledge and learn new skills.
Seek Weight Management Training
Because 93% of primary care providers believe that additional training would help them better care for overweight and obese patients, a promising first step is to seek additional training in weight management. This can be achieved by seeking out CMEs related to weight management or attending a more intensive training by one of several reputable educational institutions (Harvard Medical School Department of Continuing Education is one, for example).
Apply the 5 As
The 5 As for behavioral change apply to obesity counseling, too, but all 5 As must be discussed in order to empower the patient to change. This means physicians need to be comfortable enough in their knowledge level to advise and assist. When applied to obesity, the 5 As look like this:
- Ask permission to discuss the patient’s weight in a helpful and nonjudgmental way
- Assess waist circumference, body mass index, and stage of obesity
- Advise the patient regarding the potential risks and complications associated with obesity, the benefits of losing weight, the importance of having a long-term strategy in place, and their possible treatment options
- Agree on realistic lifestyle changes and targets
- Assist the patient in identifying the barriers to weight loss along with tools and resources to overcome those barriers
Take the Weight Implicit Association Test (IAT)
Some physicians don’t counsel overweight patients because they have a known or unknown bias against overweight patients that leads them to believe the patient is too lazy or lacking the willpower to lose weight. Even more alarming, physicians who have an anti-fat bias are less likely to build rapport with the patient in the same ways they build rapport with thinner patients. Doctors can complete the IAT for free online (https://implicit.harvard.edu/implicit/demo) to identify their own bias. If bias is identified, providers can seek additional training to improve their communication skills and, more specifically, to connect with and counsel overweight patients.
Discuss BMI as a Vital Sign
Many doctors feel they don’t have time to counsel patients on weight, but discussing BMI just as if it were another vital sign is a great way to open the door for discussion quickly and get weight on the to-do list of the appointment. It’s also important to consider the benefits of breaking down the information and consistently mentioning it at each visit over time rather than building a long-term plan in a single appointment with many other conditions to discuss. When providers mention weight at every appointment, the conversation is easier to accommodate.
Keep a List of Resources on Hand
In many cases, primary care providers will treat overweight and obese patients before they feel they have the training and expertise needed to help them achieve lifestyle change and resulting weight loss. By knowing which resources are available locally (healthcare administration can assist with this) and having the list on hand in each exam room, providers can feel confident discussing weight and referring the patient to a support group, organization, or clinic for further evaluation and treatment.
- Two-thirds of patients are overweight, but few note that their primary care provider has discussed their weight with them
- Primary care providers don’t talk about weight because of time constraints, lack of knowledge/training, or unknown biases against overweight patients
- Administration and providers can improve these numbers through additional training, application of the 5 As, identification of underlying bias, breaking the discussion into small, routine pieces, and keeping a list of local resources handy