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Advise & Consent: Talking to Obese Patients About Their Weight

Obesity is such a sensitive issue that many physicians avoid discussing it. Here are some tips on the right (and wrong) ways to broach the subject.
Talking to patients about their weight is a critical task that many physicians find difficult — and even embarrassing. Too many physicians find it so uncomfortable that they avoid it altogether. Or they become so frustrated because “patients don’t listen” that their approach ends up being counter-productive.

But it is worth the effort because it can make a big difference if done in a sensitive manner, according to Scott Kahan, MD, MPH, medical director of the Strategies to Overcome and Prevent (STOP) Obesity Alliance at George Washington University.

“There has been a lot of research over the past few years showing that doctors can productively talk to patients about obesity,” Kahan says. “Doctor-patient conversations lead to many positive obesity-related behavior changes. There is a much higher likelihood that the patients will realize that obesity is a health issue, that they will put an obesity management plan in place, and that they will lose clinically meaningful amounts of weight and keep that weight off.”

“Every single patient who comes into my office is explicitly asking for my help around weight management, yet when we start talking about weight, I always start by asking if it’s okay to talk about it.” – Scott Kahan, MD, MPH, medical director, Strategies to Overcome and Prevent (STOP) Obesity Alliance, George Washington University, Washington D.C.

Despite all the medical problems that accompany obesity, physicians tend to avoid the topic — few patients with obesity even have the condition documented in their medical record. A third of the patients who came to a University of Virginia clinic because they were considering bariatric surgery did not even consider themselves to have obesity — clearly physicians along the way had not given them a realistic view of their weight and its effects.

To help doctors overcome the barriers to talking to patients about their weight — and highlight the best approaches — Kahan and the STOP Obesity Alliance developed a web-based tool called the “Why Weight?” guide.

The tool’s focus is not on the advice to give, but how to give it.

The Physician’s Own Barriers

Doctors often say that there is so much to cover in a visit that they don’t have time to talk about weight, but they can at least start a conversation, Kahan says. “You don’t have to do it all at once. This isn’t something that you solve in a single visit. This is a chronic disease, like diabetes. You can make progress with each discussion. Fifteen minutes here and 15 minutes there over the course of months and years can be really helpful,” Kahan says. “And you don’t have to do it all by yourself.” There are a plethora of resources, including dietitians, community programs, and even commercial programs like Weight Watchers, that can take the burden off the healthcare provider.

An important aspect of preparing the groundwork for the conversation is accommodating the patient’s size in a way that keeps the patient comfortable and encourages collaboration. Examples include having a high-capacity scale to fit patients whose weights exceed 300 or 350 pounds and offering a wide-based chair that a patient can sit in without fear of breaking it.

Permission to Start the Conversation

Physicians can deflect some of the sensitivity about weight by asking permission to even bring it up. “Weight is a very personal issue that many patients have had to deal with their whole lives. They have had to deal with a lot of stigma and a lot of teasing,” Kahan says. “In my experience, asking permission is an extremely valuable strategy, and this is coming from a doctor who specializes in obesity. Every single patient who comes into my office is explicitly asking for my help around weight management, yet when we start talking about weight, I always start by asking if it’s okay to talk about it.”

Physicians should also strive to make the language they use nonjudgmental. “We don’t call patients by the condition. Just as we don’t call patients diabetic anymore — we refer to ‘having diabetes’ or ‘a patient with diabetes’ — it’s the same with obesity,” Kahan says. “We don’t call patients ‘obese,’ but instead ‘a patient with obesity’ or ‘a patient who has obesity.’ Patients tend to respond much better to more neutral language that doesn’t feel off-putting and stigmatizing.” They may also respond better to other neutral terms, such as “weight” rather than “obesity.”

Motivational Interviewing

Physicians need to explore their own implicit assumptions and biases about obesity to ensure that they don’t give patients a feeling of being judged, and move past their accustomed prescriptive approach in favor of a more collaborative effort called motivational interviewing.

“Motivational interviewing is an open-ended way of interacting built around helping patients go from being disinterested in or against a behavior change, to taking steps toward being willing to make some changes,” Kahan says. “It is an open-ended approach to trying to learn where the patient is coming from and what they want, and helping them lead the way toward positive behavioral changes. It starts with trying to get the patient to open up about their feelings, rather than assuming we know who they are, and then together coming up with a set of initial steps they can take.”

Donna Ryan, MD, professor emerita at Pennington Biomedical Research Center in New Orleans, says that she uses the guide in presentations to physicians about engaging patients about weight management: “Doctors need a script for what to say and how to say it. The model that doctors have been trained with is that they educate the patient on what to do. The new model is that doctors engage the patient and then the patient activates behavior change.”

— Seaborg is a freelance writer based in Charlottesville, Va. He wrote about how biotin could affect thyroid tests in the January issue.

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