Effective obesity treatment starts with a conversation

ORLANDO — Successful weight loss starts with a conversation that many clinicians never have with their patients, a primary care obesity specialist says here.

Obesity has become widely recognized as a disease, but many clinicians and patients still do not approach the condition as a disease. Existing in medical and social environments of prejudice and stigma, many obese patients continue to blame themselves for the disease and see it as their responsibility to address the problem, said Angela Golden, DNP, FNP-C, of the NP Obesity Treatment Clinic in Flagstaff, Arizona at the meeting of the American Association of Nurse Practitioners.

The ACTION study, one of the largest obesity studies ever, involved 3,008 patients with a body mass index (BMI) of 30 or higher, and 606 healthcare professionals. The study showed that two-thirds of patients viewed obesity as a disease, but only 55% had a formal diagnosis, and a similar proportion of patients did not believe obesity affected their future health. Additionally, 82% of patients said their condition was their sole responsibility.

“Think about it for a minute,” Golden said. “If patients thought cancer was a real disease, do you think only 18% would think they didn’t need medical help? What chronic disease is there that 82% of people with this chronic disease think it’s their entire responsibility to treat There’s nothing else. That’s it. It’s the last disease that people think they have total responsibility for.

When asked why obese patients don’t seek help to lose weight, two-thirds of healthcare providers said patients were embarrassed to talk about it. More than half said obese patients are not motivated to lose weight and/or do not believe patients can lose weight. Almost half of providers (47%) said patients did not want to lose weight.

Interviews with a subgroup of 823 patients from the ACTION study who did not seek help to lose weight revealed a different story: 15% said they were embarrassed to talk about their condition and 21 % said they were not motivated to lose weight.

Research has shown that “weight stigma” harms a person’s health by contributing to obesity, metabolic disorders, psychological disorders and mortality. Another one recent study showed that weight bias and stigma negatively affect the approach to clinical management of obesity, limit reimbursement, prevent obese patients from seeking health care, and ultimately contribute to increased obesity. morbidity and mortality.

The bias extends to health insurance coverage, Golden said. Employers who offer health insurance have the choice of opting for obesity coverage. Insurers often classify drugs used to treat obesity as “vanity” drugs. A GLP-1 agonist to treat diabetes is not considered a vanity drug, but when the same drug is used to treat obesity, it is, she said.

“It’s a bias in our healthcare system,” Golden said. “What does this mean? It prevents patients from seeking treatment. There are 13 obesity-related cancers whose rates are increasing in the United States. One of the reasons they are increasing is that the patients are not going to get preventative care because of the prejudice and stigma they have had towards them in the health care setting.This causes their cancer to be diagnosed later, and we get mortality and morbidity higher.

Weight-related stigma and bias often end the necessary conversation between healthcare provider and obese patient before it even begins.

“I’ll never forget the day I sat in a room with my dad for one of his visits,” Golden said. “The [medical assistant] does her size, but she didn’t even put it on the scale. My father had a serious illness. He probably weighed around 350 pounds. All she asked him on the way out was, “Russell, are you diabetic?” ‘Nope.’ ‘Ok thank you.’ My dad looked at me and asked, “Do you think she even saw me?”

“I know why she didn’t weigh it,” Golden continued. “She was afraid the ladder wouldn’t go that high. I don’t think she did it out of bad intentions, but that kind of stigma is really why it’s a disease not like the others. We need to have the conversation about how to have this conversation with people.”

The conversation begins with the clinical environment. An office with a cramped layout or furnishings that do not take into account the physical characteristics of the clientele can be intimidating or lead to uncomfortable or embarrassing encounters for obese patients. Patients should find the clinical environment safe, accessible, accommodating, comfortable, welcoming and shameless, Golden said. This includes reading materials in waiting rooms that focus on health habits, for example, as opposed to the latest diets and “being slim.”

The same qualities should extend to exam rooms. If a patient must undress, extra-large gowns should be readily available. Scales should be placed in an inconspicuous location and have a capacity greater than 400 pounds. Toilets should also be designed to accommodate tall people. Examination tables should be sturdy and wide, and a similar study stool or steps with handles should be available to help patients climb onto the table.

Tall patients are often overlooked when purchasing medical devices. Devices should include extra-long needles to facilitate blood draws, long or wide vaginal specula, urine specimen collectors with handles, and a tape measure at least 72 inches long.

Language opens the door to a fruitful discussion about obesity. Golden said she would like to standardize the term obesity to remove the stigma and prejudice associated with it. In fact, she would prefer to eliminate the use of the term entirely and goes so far as to advocate for it with dictionary publishers. She argues that obesity is a term that is often whispered about in much the same way as when mental health was shrouded in greater stigma and prejudice in years past.

To encourage conversation with obese patients, Golden recommends the use of terms such as overweight, increased BMI, unhealthy or healthier weight, eating habits and physical activity. Words that can discourage conversation, she says, include fat, diet and exercise, and obesity.

Borrow published workGolden suggests a conversation based on the 5As:

  • Ask permission to discuss weight
  • Assess BMI, waist circumference and stage of obesity
  • Advice on the health risks of obesity and the benefits of weight loss
  • Agree reasonable expectations and goals
  • Help the patient identify barriers to optimal health

“American needs all providers to start treating this disease and its complications,” Golden said. “Make sure your practice is a safe haven. Start the conversation and make sure follow-ups happen. Above all else, understand the biases obese people face.”

  • Charles Bankhead is editor for oncology and also covers urology, dermatology and ophthalmology. He joined MedPage Today in 2007. Follow


Golden revealed relationships with Alfasigma, Novo Nordisk, Acella, Scynexis, Hisamitsu, Gelesis, and Currax.

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