Tread lightly: Discussing obesity difficult for internists
By Leah Lawrence
Internists are increasingly viewed as the first in line to tell patients that they are obese. Many are uncomfortable delivering this message, and it's not their fault.
Research by the Strategies to Overcome and Prevent (STOP) Obesity Alliance found that among 290 primary care physicians surveyed by mail between Sept. 1 and Dec. 21, 2009, 89% believed it was their responsibility to help their overweight or obese patients to lose weight. Unfortunately, 72% of the physicians surveyed also said that they lacked training to deal with issues related to weight loss.
Physicians should screen and counsel for obesity, but how? Photo by Digital Vision
“There have been studies that have shown that most physicians are ill-equipped to approach the topic of weight loss with patients,” said Suzanne Phelan, PhD, associate professor of kinesiology at California Polytechnic State University in San Luis Obispo, Calif.
In addition, although a lot of recommendations are available about weight loss in general, very few include specific techniques or strategies for discussing the topic with patients, said James Tulsky, FACP, professor of medicine at Duke University in Durham, N.C.
“There is definitely a lack of training,” Dr. Tulsky added. “There is no doubt about that. It has been demonstrated again and again that physicians generally are not familiar with most successful counseling methods and continue to use prescriptive methods instead of counseling patients. They clearly have not been taught a successful skill set.”
The U.S. Preventive Services Task Force's 2003 guidelines for screening for obesity, defined as a body-mass index greater than or equal to 30 kg/m2 in adults, recommend that “clinicians screen all adult patients for obesity and offer intensive counseling.”
“However, it doesn't say what this ‘intensive counseling’ should look like,” Dr. Tulsky said.
Recent data taken from the National Health and Nutrition Examination Survey estimated that as much as 34% of the U.S. population is classified as obese, using the definition of BMI greater than or equal to 30 kg/m2. Increasingly, there is an urgent need to address obesity among patients to reduce rates of serious related comorbidities as well as related costs.
Even if more training were available, however, several other barriers can deter physicians from devoting more time to weight loss counseling. Chief among them may be that physicians believe such counseling will not work.
In fact, one study by Ferrante and colleagues published in Obesity in 2009 found that of 500 surveyed family physicians, 51% agreed that treatments for obesity are often ineffective, 34% said they were pessimistic that patients would be successful in losing weight, and 66% said that dealing with obesity and weight loss is frustrating.”
Complicating matters, patients may not recognize that they may be overweight or obese. In a research letter published in October 2010 in Archives of Internal Medicine, Tiffany Powell, MD, MPH, and colleagues found that body size misperception, defined as a failure to recognize the need to lose weight, is prevalent among obese adults, especially ethnic minorities, leading to a general overestimation of health and an underestimation of risk.
“What we found was that those patients with misperception had the same risk factors as other individuals with obesity, but the danger was that they didn't seem to recognize that they are at risk for these diseases as well,” said Dr. Powell, a senior cardiology fellow at University of Texas Southwestern Medical Center at Dallas.
“As physicians, we may need to take a step back and actually find out from our patients how they view themselves,” she said. “Misperception exists and it may be a barrier to patients losing weight.”
John La Puma, FACP, director of the Santa Barbara Institute for Medical Nutrition and Healthy Weight, agreed. Physicians' assumptions that patients already recognize their weight problems probably contribute to undiagnosed obesity, he noted.
Communicate the need
Although it's difficult, physicians should work past existing barriers to discuss weight loss with their patients. Generally, the approach to the topic will need to be tailored to each specific patient.
“However, just broaching the topic of weight is important,” Dr. Phelan said.
According to Dr. Phelan, previous research has found that patients who said their physicians counseled them about weight loss were up to twice as likely to report trying to lose weight.
When communicating the need for weight loss to patients, Dr. Tulsky and colleagues found motivational interviewing to be an effective technique. Their study, published in October 2010 in the American Journal of Preventive Medicine, found that patients counseled with consistent motivational interviewing techniques had lost the most weight three months post-encounter compared with patients counseled with inconsistent motivational interviewing techniques.
According to Dr. Tulsky, motivational interviewing revolves around a collaboration between the patient and the physician. In the study, the researchers wrote that “motivational interviewing includes understanding the patients' perspective, accepting patients' motivation or lack of motivation for change, helping patients find their own solutions to problems, discover their own internal motivation to change and affirming the patients' own freedom to change.”
For example, motivational interviewing techniques include such methods as treating the patient like an expert, using reflection, and avoiding confrontation and judgment.
Dr. Tulsky said he is currently working on a study in which physicians' conversations with patients are audio-recorded and then are delivered to them with feedback through an interactive teaching website. He has created a similar product for oncologists.
“When you look at trying to help someone change a lifestyle or behavior, you have to look at what their motivation is,” Dr. Tulsky said. “Instead of starting by telling them they have a weight problem, we recommend saying things like, ‘What do you think about your weight?’”
Dr. La Puma, whose practice focuses exclusively on nutritional and lifestyle issues, also believes that the key to success is in finding a patient's motivation.
“Find something that your patient is good at, or a defining personality trait,” Dr. La Puma said. “Try to find that singular strength and then redirect it toward their weight. I also ask, ‘How will your life be different when you lose 30 or 50 pounds?’ to find another goal they want to achieve.”
According to Dr. Tulsky, methods like motivational interviewing are not much more time intensive than what most physicians are already doing. It's just a matter of changing how you frame questions, he said.
“I would argue that right now doctors are spending, on average, three minutes out of every 20-minute encounter talking about weight,” he said. “They could probably, if they used effective techniques, spend the same three minutes, or maybe four or five, talking about weight [using motivational interviewing] and it would be more effective.”
Even more specifically, a study by Dutton and colleagues indicated that physicians should avoid terminology that patients consider undesirable, such as “fatness,” “excess weight,” or “large size,” and stick with terms rated as more desirable, such as “weight,” “BMI,” and “unhealthy body weight.”
When patients don't recognize a weight problem, Dr. Powell and Dr. Tulsky both recommend starting a conversation to help them learn about obesity's potential impact. For example, physicians could share general information about health, diet, exercise and weight.
Not all patients will make a change immediately, Dr. Tulsky admitted, but educating them may force them to think about the situation and get them ready to change at their next visit.
“Remember, people don't change overnight,” he said.
To overcome time constraints, physicians can give simple, quick advice to patients who are ready to make a change, or to all patients regardless of the reason for their visit.
“Simple things you can tell people are ... avoid sweetened beverages, increase physical activity, eat more fruits and vegetables, weigh yourself every day and get more sleep,” Dr. Tulsky said.
Internists should not overestimate patients' knowledge of these simple weight-loss techniques, which may seem like common sense to most physicians, he added.
Among Dr. La Puma's tested strategies are advising patients to always eat breakfast, even if they are not hungry, to avoid eating three to four hours before going to bed at night, and to cook more meals at home.
“Even if they only attempt one or two of these strategies, it makes a noticeable difference,” Dr. La Puma said. “And then they have experienced a small success, on which they can build.”
These tips and strategies are so easy to communicate that it might be a good idea to incorporate them into most internist-patient conversations, the experts said, especially since people do not always self-identify as overweight or obese. In addition, as societal norms change, practitioners and non-practitioners alike struggle to “eyeball” overweight patients, Dr. Phelan said.
Regardless of whether a patient is lean or overweight, Dr. Phelan said, physicians should be asking them what types of foods they're eating and how much they are exercising.
“Internists have lean patients who are at risk for cardiovascular disease, so this needs to occur across the board,” she said. “That approach will take away some of the stigma. It will allow physicians to focus on the behavior of the patient and not just the weight.”
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Flegal K, Carroll MD, Ogden CL, Curtin LR. Prevalence and Trends in Obesity Among US Adults, 1999-2008. JAMA. 2010;303:235-241.
La Puma J, Szapary P, Maki KC. Physicians recommendations for and personal use of low-fat and low-carbohydrate diets. Int J Obes (Lond) 2005; 29:251-253.
Miller WR, Rollnick S. Motivational Interviewing: Preparing People to Change. New York: Guilford Press; 2002.
Rollnick S, Butler CC, Kinhersley P, et al. Motivational interviewing. BMJ. 2010;340:c1900.
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Phelan S, Nallari M, Darroch FE, Wing RR. What do physicians recommend to their overweight and obese patients? J Am Board Fam Med. 2009;22:115-122.
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Pollak KI, Alexander SC, Coffman CJ, et al. Physician communication techniques and weight loss in adults: Project CHAT. Am J Prev Med. 2010;39:321-328.
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