Talking About Obesity

Posted on December 27, 2012

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weight-loss-scale-helpDuring my family medicine rotation, I noticed the physicians I worked with focused more time on weight management than in any other outpatient clinic I had worked in.  Recently, while on a less demanding elective, I decided to conduct my own observational study.  How often, and with what prompting, do physicians address their patients’ weight?

Note that this is simply a small observational series and was conducted independently, without any IRB or peer review process.  Despite the informal nature of the data collection, the findings will be presented in a traditional format.

Background:

In spite of growing national awareness, greater emphasis on obesity and diet-related illnesses in the media, and a booming weight-loss industry, Americans continue to struggle to maintain healthy weights – recent data demonstrate that two thirds of Americans are overweight or obese[1].

It has been documented that family physicians spend more time discussing weight loss than internists[2], but less data is available for other specialties.  The objective of this study was to determine how often non-primary care physicians discuss weight loss with patients in a context where maintenance of a healthy weight would be directly related to patient presenting complaints (i.e. a rheumatology practice).

A rheumatology practice was determined to be an ideal setting, given that a majority of patients present with osteoarthritis (OA) complaints. Research has demonstrated that each 1-pound reduction in weight translates to a 4-pound reduction in stress on the knees[3], and that weight loss is associated with a subjective improvement in function in persons with OA[4,5].  Thus, weight management is expected to be prioritized for a large proportion of patients in whom it would be appropriate.

Methods:

During 4 consecutive weeks at a suburban outpatient rheumatology practice, patient-physician interactions were observed for opportunities to discuss patient overweight/obesity in patients with a BMI > 25 kg/m2.  Patients included were male and female, ages 18-94 years.  Only patients for whom the entire patient-physician interaction was observed were included, and data from patients who were first seen by one of the practice’s nurse practictioners (NPs) or who were interviewed by the observing medical student were excluded.

Any mention of weight loss or obesity was documented, and dialogue was graded as either physician-initiated (PhI) or patient-initiated (PaI); the number of times a patient mentioned their weight before it being acknowledged by the physician was also documented.  For all interactions, the discussion of weight loss or obesity was categorized into those merely mentioning weight loss (weight loss only; WLO), diet (D), exercise (E), or both diet and exercise (D&E).

Results:

The interactions of 169 individual patients were included during the observation period.  A total of 117 (69%) of these patients met criteria for overweight/obesity.  Weight management was discussed in only 17 (14.5%) of interactions with overweight/obese patients (Table 1), and was nearly twice as likely to be patient-initiated (9.4%) than physician-initiated (5.1%).  In total, patients mentioned their weight without prompting from the physician in 18 (15.4%) interactions.

obesity table 1

Table 1. Patient & weight discussion characteristics.

Physicians were more likely to mention exercise when discussing weight loss than diet, and none discussed diet alone (Table 2).  Exercise without mention of weight or weight loss was mentioned in 3 interactions.  Eighteen (15.4%) overweight patients spoke about their weight, which was acknowledged by the physician only 11 (9.4%) times, and was thus ignored or overlooked by the physician in 7 instances.

Table 2.  Physician’s weight management advice.

Table 2. Physician’s weight management advice.

If acknowledged, weight loss was generally addressed by the physician after a single mention, but on several occasions was not acknowledged until mentioned by the patient multiple times, and on one occasion was mentioned 5 times by the patient before being acknowledged.  In 6 (5.1%) instances, the patient’s weight was discussed outside of the exam room with either the observer or another healthcare provider, but not with the patient.

Discussion/Conclusions:

Physicians are reluctant to discuss weight loss with patients in whom it is indicated and likely to be beneficial.  Barriers to discussing weight loss must be considered and addressed, including physician attitudes towards the effectiveness of discussing weight loss, efficacy of weight loss as it relates to the patient’s presenting complaint, lack of physician incentives, the belief that weight management is the responsibility of the primary care physician, and lack of physician self-efficacy with regard to nutritional advice[6,7].

Patients are also unlikely to discuss their weight, mentioning it in only a minority of interactions where it would have been appropriate.  Patients may have their own barriers to discussing weight loss, including self-esteem, prior unsuccessful attempts at weight loss, and the belief that it’s the physician’s duty to begin the discussion.

Limitations to the study include the presence of an observer in the room, OA of the knee(s) not being the primary complaint of the patient, and the observation of only one interaction per patient, amongst others.

Efforts should be focused at lowering the barriers to in-office discussions of weight management, just as we strive to encourage smoking cessation at every visit, regardless of specialty. Current and future generations of physicians must be encouraged to discuss weight loss when appropriate, and we should strive to let no patient request to do so go unacknowledged.  In many cases, a proper discussion about weight loss cannot be conducted in the allotted time, especially if other issues are the primary reason for the patient’s visit.  Thus, patients should be encouraged to make a dedicated appointment with the advising physician, their PCP, or another qualified consultant for more dedicated assessment and planning, and all offices should be prepared to make such referrals if they are unable to provide the necessary services.

References:

[1]  “FASTSTATS – Overweight Prevalence.” Centers for Disease Control and Prevention. CDC, 10 Oct. 2012. Date accessed: 20 Dec. 2012. <http://www.cdc.gov/nchs/fastats/overwt.htm&gt;

[2]  Pollak KI, et al. “Predictors of Weight Loss Communication in Primary Care Encounters.”  Patient Educ Couns. 2011 December; 85(3): e175–e182.  PMCID: PMC3154469

[3]  Messier SP, et al.  “Weight loss reduces knee-joint loads in overweight and obese older adults with knee osteoarthritis.”  Arthritis Rheum. 2005 Jul;52(7):2026-32.  PMID: 15986358

[4]  Christensen R, et al.  “Weight loss: the treatment of choice for knee osteoarthritis? A randomized trial.”  Osteoarthritis and Cartilage.  2005 Jan;13(1):20-27.

[5]  Bliddal H, et al.  “Osteoarthritis – a role for weight management in rheumatology practice:  an update.”  Clinical Obesity.  2011 Mar;1(1): 50-52.

[6] Befort CA, et a.  “Weight-Related Perceptions Among Patients and Physicians.”  J Gen Intern Med. 2006 October; 21(10): 1086–1090.

[7]  Vetter ML, et al.  “What Do Resident Physicians Know about Nutrition? An Evaluation of Attitudes, Self-Perceived Proficiency and Knowledge.”  J Am Coll Nutr. 2008 April; 27(2): 287–298.

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