Keys%20to%20Communicating%20with%20Patients%20about%20Obesity

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Keys to Communicating with Patients about Obesity
2
Overview

• Sociocultural context
• Anti-fat attitudes
• Starting the conversation
• Managing unrealistic expectations

3
Physicians Attitudes

• 40 attributed obesity to a lack of willpower1
• 66 viewed obese patients as lacking
  self-control, and over 30 considered them
  lazy and sad2

1 Harris et al. JAOA, 1999. 2 Price et al. Amer
Journal of Preventive Medicine, 1987. Adams et
al. Women Health, 1993.
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Attitudes about Obese Patients
Adjectives (1 7) Endorsed
Awkward 61.7
Unattractive 53.2
Noncompliant 50.8
Ugly 49.5
Weak-willed 44.0
Sloppy 34.7
Lazy 29.7
Unpleasant 9.0
Dishonest 3.4
Foster GD et al. Obes Res, 11 1168-77, 2003.
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Beliefs About the Causes of Obesity
1 Not At All Important to 5 Extremely
Important
Causes of Obesity Percent
Physical Inactivity 84.3
Overeating 69.0
High Fat Diets 67.8
Genetic Factors 50.7
Poor Nutritional Knowledge 46.4
Psychological Problems 44.5
Repeated Dieting 35.7
Lack of Willpower 32.6
Restaurant Eating 30.9
Metabolic Defect 19.5
Endocrine Disorder 11.6
Foster GD et al. Obes Res, 11 1168-77, 2003.
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Patient Attitudes Toward Physician Treatment of
Obesity

• 88 of obese patients seeking bariatric surgery
  reported always or usually being treated
  disrespectfully by the medical profession

Rand MacGregor. Southern Medical Journal, 1990.
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Patient Attitudes Toward Physician Treatment of
Obesity

• Physicians negative attitudes toward obesity
  contribute to obese patients avoidance of
  seeking routine, preventive medical care
• Reasons given by obese patients for such
  avoidance include insensitive comments about
  weight, physician disapproval of patient size and
  being made to feel that weight is their most
  important characteristic

Robinson et al. JABFP, 1995.
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Managing Your Own Attitudes

• Acknowledge them
• Be aware of likely triggers
• Discuss feelings with your colleagues

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Likely Triggers

• Behaviors/attitudes that approximate the
  stereotype
• Factors leading to decreased tolerance
• Unwanted clinical outcomes

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Making the Office Environment Receptive

• Have gowns available that fit larger patients
• Buy a scale that can weigh all of your patients
• Use larger blood pressure cuffs when appropriate
• Provide some armless chairs in the waiting room
• Include the whole office team

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Talking about Obesity

• Few physicians talk about obesity
• Futility and avoidance (Frank, JAMA 1993)
• Limitations of the busy practice environment

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Changes in Body Weight
Placebo
Metformin
Change in Weight (kg)
Lifestyle
Year
Diabetes Prevention Program Research Group. N
Engl J Med 2002346,393-403.
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Diabetes Prevention Program
Placebo
Metformin
Lifestyle
Cumulative Incidence of Diabetes ()
Year
Diabetes Prevention Program Research Group. N
Engl J Med. 2002346,393-403.
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National Weight Control Registry

• To qualify, individuals must have maintained at
  least a 30 lb. weight loss for a minimum of 1
  year.
• Over 4500 current members
• Average age 45 years
• Average weight loss reported by participants is
  30kg
• Average duration of weight maintenance is 5.5
  years

Wing Hill. Annu Rev Nutr, 2001.
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Thin for Lifeby Anne M. Fletcher, M.S., R.D.

• Shares techniques of people who have succeeded in
  keeping weight off for good
• Refutes the popular notion that losing weight
  permanently is hopeless

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• Imagine that you are visiting your doctor for a
  check-up. The nurse has measured your weight and
  has found that you are at least 50 lb over your
  recommended weight. The doctor will be in shortly
  to speak with you. Please indicate how desirable
  or undesirable you would find each of the
  following terms if your doctor used it.

Wadden TA et al. Obes Res. 200311(9)1140-6.
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Obese Women (N 167)
Wadden TA et al. Obes Res. 200311(9)1140-6.
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Obese Men (N 52)
Wadden TA et al. Obes Res. 200311(9)1140-6.
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Assessing Readiness

• Why now?
• What changes will you have to make?
• What will change if you lose weight?
• What do others think about your weight?
• What else is going on in your life?

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Assessing Readiness

• We are not good at predicting outcomes.
• Patients ultimately make the decision.
• Providers assess costs/benefits in a variety of
  contexts.

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5 Steps to Behavior Change

• 1. Have patient identify specific goals
• Activity (i.e., one specific goal for exercise)
• Intake (i.e., one specific goal for diet)
• 2. Identify when, where, and how behaviors will
  be performed
• 3. Have patient keep record of behavior change
  (i.e., diet and activity diaries)
• 4. Follow-up progress at next treatment visit
• 5. Congratulate patient on successes do not
  criticize shortcomings

Wadden Foster. Medical Clinics of North
America, 2000.
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Establishing Supportive Relationships

• Consistent
• Non-Judgmental
• Observant
• Respectful

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Facilitating Long-Term Retention

• Celebrate therapeutic landmarks
• Acknowledge personal landmarks
• Attend to life stressors and the bigger picture

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Goals for Weight Loss

• The initial goal of weight loss therapy for
  overweight patients is a reduction in body weight
  of about 10moderate weight loss of this
  magnitude can significantly decrease the severity
  of obesity-associated risk factors.

NHLBI, 1998.
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Study Design

• Subjects
• 60 obese women
• 40.0 8.7 years
• 99.1 12.3 kg
• BMI 36.3 4.3 kg/m2

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Goal Weights

• Averaged 32 reduction in body weight
• Three times greater than the goals recommended by
  the National Academy of Science and Department of
  Agriculture
• Greatly exceeds weight losses of nonsurgical
  treatments

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Defined Weights

• Dream Weight
• A weight you would choose if you could weigh
  whatever you wanted
• Happy Weight
• This weight is not as ideal as the first one. It
  is a weight, however, that you would be happy to
  achieve
• Acceptable Weight
• A weight that you would not be particularly happy
  with, but one that you could accept, since it is
  less than your current weight
• Disappointed Weight
• A weight that is less than your current weight,
  but one that you could not view as successful in
  any way. You would be disappointed if this were
  your final weight after the program

Foster et al, J Consult Clin Psychol, 1997.
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Defined Weights
Reduction
Dream 38
Happy 31
Acceptable 25
Disappointed 17
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Achieving Defined Weights at Week 48
(N 45)Weight loss 16.3 7.2 kg
Happy
Acceptable
9
24
Dream 0
20
47
Did not reach Disappointed Weight
Disappointed
Foster et al, J Consult Clin Psychol, 1997.
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Helping Patients Accept More Modest Weight Losses

• Be clear about what treatment can do and what it
  cannot do
• Discuss biological limits
• Focus on non-weight outcomes

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As with any chronic illness, we rarely have an
opportunity to cure. But we do have an
opportunity to treat the patient with respect.
Such an experience may be the greatest gift that
a doctor can give an obese patient it compares
favorably with the modest benefits of our program
of weight reduction. Albert J. Stunkard, MD
Obesity Theory and Therapy, 1993
Lippincott-Raven.