Bringing up the "O" Word on West TN Medical News 3.0

Bringing up the "O" Word

By: CINDY SANDERS

Clinicians Still Struggle to Broach Subject of Weight

My word, you're fat! Someone go see if Mr. Jones broke our scale.

While no provider (at least none we know) would bring up the sensitive subject of weight in this manner, there are many who feel that no matter how carefully words are chosen, a patient will process them as something similarly offensive.

Despite the knowledge base linking overweight and obesity to cardiovascular disease, diabetes, cancer and a host of orthopedic complaints, patients still report their providers shy away from the subject. A December 2008 study published in the Journal of Nutrition, Health & Aging by Schuster RJ, et al. found that 53 percent of physicians were not comfortable discussing obesity with their patients. A number of other studies have also underscored the negative feelings physicians have about weight management in the primary care setting. The hesitation stems from a host of concerns including:

Fear of insulting a patient,
A general belief that no matter what is said a patient won't change habits,
Frustration over inadequate time in an office visit to devise a weight loss strategy,
An unfamiliarity with available programs and resources, and
An uncomfortable feeling that a lecture from a clinician carrying extra pounds is a bit like the pot calling the kettle 'black.'

Yet, research also points to the importance of having such a conversation with patients. The perception exists that if physicians don't address the subject of weight, then it must not matter that much. Furthermore, multiple studies have concluded many patients are willing to discuss weight and its impact on health, but they crave useful advice and counseling rather than a terse, "Eat less and exercise more."

Pam Davis, RN, CBN, program director for the Centennial Center for the Treatment of Obesity, recently held a day-long event for primary care physicians in Middle Tennessee to look at proactive ways to discuss weight and obesity with patients. As Davis pointed out, there isn't a provider out there who would hesitate to address the dangers of high blood pressure or glucose levels. "Yet, there is some hesitation when we see someone with a significantly concerning weight to bring that topic up with them."

Davis continued, "I think as healthcare providers, we have the responsibility to address any issue that is patently harmful to our patients." She added, a natural conversation starter is to roll the topic into a discussion of other diagnostic findings with a patient … particularly since weight is often a contributing factor to less-than-optimal lab results. If a patient doesn't exhibit signs of pre-diabetes, hypertension or cardiovascular disease but has weight trending upward, physicians have the opportunity to frame discussions in terms of prevention.

Resource for Providers

http://win.niddk.nih.gov

WIN — Weight-control Information Network is an online resource of the National Institute of Diabetes and Digestive and Kidney Diseases and features publications for patients and providers to open the dialogue about healthy weight goals. The site also includes data on national trends and statistics linked to overweight and obesity and information regarding the latest research.

"Talking with Patients About Weight Loss: Tips for Primary Care Professionals" offers practical advice and conversation starters to address weight and frame realistic goals in partnership with patients. To view this document, go online to http://win.niddk.nih.gov/publications/talking.htm.

The first step, Davis said, is assessing whether or not a patient is ready to lose weight. "The reality may be for some patients the goal is just not to gain more weight." Davis noted an easy statement for a physician to make would be along the lines of: 'I'm really concerned about your weight, and I think we need to focus on making sure it doesn't get any higher.'

Then, she said, it's important to spend some time talking with the patient about what barriers exist to making better food choices or moving more. Equally important is to build upon healthy habits that are already in place. It's also worthwhile, Davis noted, to find out if other methods have worked or failed in the past. Often just by taking the time to talk, a provider empowers a patient to begin the journey to a healthier weight. "Patients feel like here is someone ready, willing and able to work with me on this chronic problem," she said.

Davis added practical advice and realistic goals are keys to a sustained effort. Rather than solely focusing on the long-term goal, patients need incremental goals to celebrate along the way. She suggested the provider assign "homework" — one or two personalized goals to hit in the next month.

During the conversation to discern weight loss barriers, a physician might discover fast food is the dinner choice four nights a week or that a patient drinks five carbonated beverages a day. In that case, practical goals might be to reduce soft drinks to no more than two a day and to collect nutrition guides from fast food restaurants and look for healthier options.

Davis noted keeping a food journal for two weeks is one of the simplest, least expensive and most effective tools from which most every patient benefits. She suggested, however, the journal not simply be a log of what a patient ate in a day. Instead, it should also include portion sizes, time of day food is being eaten, the setting, emotions when eating, and actual hunger level when eating. "Nothing stands out better than going back and seeing what you're really doing in writing," she said.

If the patient comes back in a month and hasn't lost weight or has gained more, she advised providers not be critical but instead to focus on what worked and what went wrong. Look for items to tweak before the next appointment. If a patient held steady or lost even a little bit, acknowledge the accomplishment and search for ways to build the momentum. "Again, they have got to celebrate those successes."

Davis concluded, "Anyone who has ever dieted realizes dieting is hard. If it were easy, everyone would be in the normal BMI range. We have to be supportive of any positive results that our patients can achieve."

Even when patients make incremental improvement in decreasing weight and increasing activity levels, it's certainly a step in the right direction.