Be Sensitive Addressing Weight Management

It’s a new era in weight management and the treatment of overweight and obesity with the rise of glucagon-like peptide 1 receptor agonist medicines. Some patients are showing a new readiness and comfort in discussing treatment with their providers.

But sometimes, the conversation doesn’t get past a handful of words, and just the attempt may threaten the therapeutic relationship.

Experts who have had hundreds of these conversations say it’s important to uncover what you as a provider may unknowingly harbor and bring to conversations about weight. And they also acknowledge there are a variety of ways to talk about it. Sometimes, that’s a straightforward path, and sometimes terms like “weight,” “pounds,” or “obesity” are never even uttered.

Start With Provider Stigma

“Weight and obesity have such a strong current within our society of blame the victim, as well as self-blame by the victim, so it is a delicate one to bring up,” said Jonathan Q. Purnell, MD, fellow and vice president of The Obesity Society and professor of medicine at Oregon Health & Science University, Portland, Oregon.

There was a time not so long ago when the prevailing philosophy was to always make a weight-related diagnosis, recalled Amy Krebs, FNP-C, MSN, RN, who works in a busy Duke Health primary care clinic in Chapel Hill, North Carolina.

“But then people started to feel like weight was being connected to every little healthcare issue that they have. And we have a huge problem within medicine of weight stigma and implicit bias towards weight,” said Krebs, who maintains both a traditional primary care patient roster and specializes in providing weight management consults in the primary care setting.

“A way to be sensitive about that topic is to approach it as being aware that bias is there and knowing that while weight can be a health-based risk factor for many things, it is not the be-all, end-all of someone’s health,” said Krebs, who recommends providers take the Implicit Association Test for weight. She has used the test herself to evaluate the effectiveness of her own efforts to manage implicit bias.

A common recommendation is to start a conversation about weight management by asking permission.

“Is now a good time for us to discuss how your weight and health may be affecting each other and how we can work together on it?” is one way to phrase the question, according to the STOP Obesity Coalition’s “Weight Can’t Wait” publication crafted for the primary care providers.

Krebs also starts a conversation asking permission, although she emphasizes that reading the room to evaluate whether the moment is right is also important. She doesn’t ask when a patient comes in to see her for, say, acute anxiety, or to be treated for the flu.

Asking permission is not some kind of safe bypass of bias, though.

“The key to treating patients with obesity — and this also is true of any patient that you treat — is to treat them with respect. And that involves understanding the condition they’re dealing with from a physiologic and pathophysiologic basis,” said Purnell.

Patients with weight management issues “have biological underpinnings of their behaviors. So obesity is probably the only chronic disease we manage in our clinic in which a behavior is part of the pathophysiologic process,” he said.

That complex relationship with the overlays brought by cultures and traditions, can result in implicit biases and stigma that are present in the exam room.

“The observed behaviors — like being hungry and looking for food, or stopping when you’re full, or maybe not stopping and having seconds — are driven by internal biological signals,” said Purnell, an endocrinologist working in a preventative cardiology setting. He also helps create professional development resources, including The Obesity Society’s training for obesity management in primary care.

If a doctor doesn’t appreciate that, he said, they often fall back on the trope of, “well, this is just a matter of willpower.”

In other words, Purnell said, show empathy.

A Non-Weight Based Approach

During a well visit, Krebs asks patients if they have any health-related goals she can help with in the coming year, and often times that may bring an opening to discuss weight management.

“We call it ‘weight management’ just to be using the words that most patients prefer to talk about it in, as opposed to obesity care,” Krebs said.

Maria Maldonado, MD, who for decades practiced primary care before recently transitioning to obesity medicine, would ask patients what terminology they were comfortable using when discussing weight.

She uses a humanistic psychology strategy called nonviolent communication that is based on the premise that we are all just trying to get our needs met. The method makes important distinctions between feelings and needs.

“Nonviolent communication lends itself to how you begin to have a conversation with patients who have really been burned in many ways by the healthcare profession in their approach to treatment of this condition,” said Maldonado, director of Wellness and an obesity medicine specialist at FORM Health, Boston. She is also a fellow of the American College of Physicians and a diplomat of the American Board of Obesity Medicine.

Maldonado said that instead of talking about why obesity treatment is important, she would instead seek a way to connect it to a patient’s intrinsic motivations.

“One thing that primary care physicians can do — and I do this in my practice all the time — is to ask people what they most want for their health,” she said. “So if they could wave a magic wand and their health was exactly what they wanted it to be in the next year or two, what would that look like?”

Next, Maldonado asks if it would be okay to discuss where the patient presently is on the path toward that vision, and lets them know it will involve taking their weight — which she always explains is just a number and is just objective information, as well as discussing what they are eating and their physical activity level.

“Going back to nonviolent communication, remember that every action that we engage in is a strategy to help us feel better. And so maybe somebody is not engaging in physical activity because they have a need for rest because they’re working two jobs,” Maldonado said. “We need to sort of normalize and show a lot of empathy for where a person is today. So you get that entire picture of where we stand.”

Listening for Internalized Stigma

There isn’t any formal measure suggesting that the medical community as a whole is improving in talking with patients about weight management and obesity care, but there are growing efforts toward that goal.

“We are starting to see not just increased research on weight stigma and how to address this in healthcare professionals, but we’re seeing more initiatives taking place to implement education and training on this topic,” said Rebecca Puhl, PhD, an expert on weight stigma and deputy director at the Rudd Center for Food Policy and Health, University of Connecticut, Hartford, Connecticut.

“Having said that, we are very far from where we need to be,” said Puhl, who helped launch a resource collection last year called Supportive Obesity Care that includes materials ranging from motivational interviewing scripts to tipsheets on how to create a welcoming office environment.

Stigma in medical care — as opposed to other areas like education or the workplace — continues to account for the vast majority of weight-based stigma instances reported to the Obesity Action Coalition, said Patty Nece, JD, a 66-year-old retired lawyer who is the immediate past chair of the organization and advocates for people with obesity.

Internalized stigma among patients can block access to care. Incorporating the impact of internalized stigma into patient care can make a big difference, Nece said. She finally discovered her own internalized weight stigma when she started going to a practice that included psychological resources.

“Making positive health changes in an environment where you are saying such incredibly negative things to yourself constantly is virtually impossible,” Nece said.