Keys to Communicating with Patients about Obesity

Overview

• Sociocultural context

• Anti-fat attitudes

• Starting the conversation

• Managing unrealistic expectations

Physicians’ Attitudes

• 40% attributed obesity to a “lack of willpower”1

• 66% viewed obese patients as “lacking self-control,” and over 30% considered them “lazy” and “sad”2

1 Harris et al. JAOA, 1999.2 Price et al. Amer Journal of Preventive Medicine, 1987.Adams et al. Women Health, 1993.

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.

Beliefs About the Causes of Obesity

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%

1 = “Not At All Important” to 5 = “Extremely Important”

Foster GD et al. Obes Res, 11: 1168-77, 2003.

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.

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.

Managing Your Own Attitudes

• Acknowledge them

• Be aware of likely triggers

• Discuss feelings with your colleagues

Likely Triggers

• Behaviors/attitudes that approximate the stereotype

• Factors leading to decreased tolerance

• Unwanted clinical outcomes

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

Talking about Obesity

• Few physicians talk about obesity

• Futility and avoidance (Frank, JAMA 1993)

• Limitations of the busy practice environment

Changes in Body Weight

-8

-6

-4

-2

0

2

4

0 0.5 1 1.5 2 2.5 3 3.5 4

Ch

ang

e in

We

igh

t (kg

)

Year

Placebo

Metformin

Lifestyle

Diabetes Prevention Program Research Group. N Engl J Med 2002;346,393-403.

Diabetes Prevention Program Research Group. N Engl J Med. 2002;346,393-403.

Diabetes Prevention Program

40

30

20

10

00 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0

Placebo

Metformin

Lifestyle

Cum

ulat

ive

Inci

denc

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Dia

bete

s (%

)

Year

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.

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

“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. 2003;11(9):1140-6.

Wadden TA et al. Obes Res. 2003;11(9):1140-6.

Weight Problem

Unhealthy Body Weight

Unhealthy BMI

Heaviness

Large Size

Excess Fat

Obesity

Fatness

Weight

Excess Weight

BMI

2 1 0 -1 -2 Very Desirable Very Undesirable

Obese Women (N = 167)

Wadden TA et al. Obes Res. 2003;11(9):1140-6.

Obese Men (N = 52)

Unhealthy Body Weight

Unhealthy BMI

Heaviness

Large Size

Excess Fat

Obesity

Fatness

Weight

Excess Weight

BMI

Weight Problem

2 1 0 -1 -2 Very Desirable Very Undesirable

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?

Assessing Readiness

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

contexts.

5 Steps to Behavior Change1. 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.

Establishing Supportive Relationships

• Consistent

• Non-Judgmental

• Observant

• Respectful

Facilitating Long-Term Retention

• Celebrate therapeutic landmarks

• Acknowledge personal landmarks

• Attend to life stressors and the bigger picture

Goals for Weight Loss

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

NHLBI, 1998.

Study Design

Subjects:

60 obese women

40.0 ± 8.7 years

99.1 ± 12.3 kg

BMI = 36.3 ± 4.3 kg/m2

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

• 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.

Defined Weights

Defined Weights

% Reduction

Dream 38%

Happy 31%

Acceptable 25%

Disappointed 17%

% Achieving Defined Weights at Week 48*

AcceptableHappy

Dream = 0%

Disappointed Did not reach Disappointed Weight

9%

47%20%

24%

Foster et al, J Consult Clin Psychol, 1997.

*(N = 45)Weight loss: 16.3 + 7.2 kg

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

“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.