1. Keys to Communicating with Patients about Obesity

2. Overview Sociocultural context Anti-fat attitudes
Starting the conversation
Managing unrealistic expectations

3. Physicians’ Attitudes
40% attributed obesity to a “lack of willpower”1
66% viewed obese patients as “lacking self- control,” and over 30% considered them “lazy” and “sad”2
1 Harris et al. JAOA, 1999.
2 Price et al. Amer Journal of Preventive Medicine, 1987.
Adams et al. Women Health, 1993.

4. Attitudes about Obese Patients
Adjectives (1 – 7)
Endorsed
Awkward
61.7%
Unattractive
53.2%
Noncompliant
50.8%
Ugly
49.5%
Weak-willed
44.0%
Sloppy
34.7%
Lazy
29.7%
Unpleasant
9.0%
Dishonest
3.4%
Foster GD et al. Obes Res, 11: , 2003.

5. Beliefs About the Causes of Obesity
1 = “Not At All Important” to 5 = “Extremely Important”
Causes of Obesity
Percent
Physical Inactivity
84.3%
Overeating
69.0%
High Fat Diets
67.8%
Genetic Factors
50.7%
Poor Nutritional Knowledge
46.4%
Psychological Problems
44.5%
Repeated Dieting
35.7%
Lack of Willpower
32.6%
Restaurant Eating
30.9%
Metabolic Defect
19.5%
Endocrine Disorder
11.6%
Foster GD et al. Obes Res, 11: , 2003.

6. Patient Attitudes Toward Physician Treatment of Obesity
88% of obese patients seeking bariatric surgery reported always or usually being treated disrespectfully by the medical profession
Rand & MacGregor. Southern Medical Journal, 1990.

7. Patient Attitudes Toward Physician Treatment of Obesity
Physicians’ negative attitudes toward obesity contribute to obese patients’ avoidance of seeking routine, preventive medical care
Reasons given by obese patients for such avoidance include: insensitive comments about weight, physician disapproval of patient size and being made to feel that weight is their most important characteristic
Robinson et al. JABFP, 1995.

8. Managing Your Own Attitudes
Acknowledge them
Be aware of likely triggers
Discuss feelings with your colleagues

9. Likely Triggers Behaviors/attitudes that approximate the stereotype
Factors leading to decreased tolerance
Unwanted clinical outcomes

10. Making the Office Environment Receptive
Have gowns available that fit larger patients
Buy a scale that can weigh all of your patients
Use larger blood pressure cuffs when appropriate
Provide some armless chairs in the waiting room
Include the whole office team

11. Talking about Obesity Few physicians talk about obesity
Futility and avoidance (Frank, JAMA 1993)
Limitations of the busy practice environment

12. Changes in Body Weight Change in Weight (kg) Year Placebo Metformin
Lifestyle
Year
Diabetes Prevention Program Research Group. N Engl J Med 2002;346,

13. Diabetes Prevention Program40 30 20 10
Placebo
Metformin
Lifestyle
Cumulative Incidence
of Diabetes (%)
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
Year
Diabetes Prevention Program Research Group. N Engl J Med. 2002;346,

14. National Weight Control Registry
To qualify, individuals must have maintained at least a 30 lb. weight loss for a minimum of 1 year.
Over 4500 current members
Average age: 45 years
Average weight loss reported by participants is 30kg
Average duration of weight maintenance is 5.5 years
Wing & Hill. Annu Rev Nutr, 2001.

15. Thin for Life by Anne M. Fletcher, M.S., R.D.
Shares techniques of people who have succeeded in keeping weight off for good
Refutes the popular notion that losing weight permanently is hopeless

16. “Imagine that you are visiting your doctor for a check-up
“Imagine that you are visiting your doctor for a check-up. The nurse has measured your weight and has found that you are at least 50 lb over your recommended weight. The doctor will be in shortly to speak with you. Please indicate how desirable or undesirable you would find each of the following terms if your doctor used it.”
Wadden TA et al. Obes Res. 2003;11(9):

17. Obese Women (N = 167) Weight Excess Weight BMI Weight Problem
Unhealthy Body Weight
Unhealthy BMI
Heaviness
Large Size
Excess Fat
Obesity
Fatness
Weight
Excess Weight
BMI
Very Desirable Very Undesirable
Wadden TA et al. Obes Res. 2003;11(9):

18. Obese Men (N = 52) Weight Excess Weight BMI Weight Problem
Unhealthy Body Weight
Unhealthy BMI
Heaviness
Large Size
Excess Fat
Obesity
Fatness
Weight
Excess Weight
BMI
Weight Problem
Very Desirable Very Undesirable
Wadden TA et al. Obes Res. 2003;11(9):

19. Assessing Readiness Why now? What changes will you have to make?
What will change if you lose weight?
What do others think about your weight?
What else is going on in your life?

20. Assessing Readiness We are not good at predicting outcomes.
Patients ultimately make the decision.
Providers assess costs/benefits in a variety of contexts.

21. 5 Steps to Behavior Change
1. Have patient identify specific goals
Activity (i.e., one specific goal for exercise)
Intake (i.e., one specific goal for diet)
2. Identify when, where, and how behaviors will be performed
3. Have patient keep record of behavior change (i.e., diet and activity diaries)
4. Follow-up progress at next treatment visit
5. Congratulate patient on successes; do not criticize shortcomings
Wadden & Foster. Medical Clinics of North America, 2000.

22. Establishing Supportive Relationships
Consistent
Non-Judgmental
Observant
Respectful

23. Facilitating Long-Term Retention
Celebrate therapeutic landmarks
Acknowledge personal landmarks
Attend to life stressors and the bigger picture

24. Goals for Weight Loss
“The initial goal of weight loss therapy for overweight patients is a reduction in body weight of about 10%…moderate weight loss of this magnitude can significantly decrease the severity of obesity-associated risk factors.”
NHLBI, 1998.

25. Study Design Subjects: 60 obese women 40.0 ± 8.7 years 99.1 ± 12.3 kg
BMI = 36.3 ± 4.3 kg/m2

26. Goal Weights Averaged 32% reduction in body weight
Three times greater than the goals recommended by the National Academy of Science and Department of Agriculture
Greatly exceeds weight losses of nonsurgical treatments

27. Defined Weights Dream Weight Happy Weight Acceptable Weight
A weight you would choose if you could weigh whatever you wanted
Happy Weight
This weight is not as ideal as the first one. It is a weight, however, that you would be happy to achieve
Acceptable Weight
A weight that you would not be particularly happy with, but one that you could accept, since it is less than your current weight
Disappointed Weight
A weight that is less than your current weight, but one that you could not view as successful in any way. You would be disappointed if this were your final weight after the program
Foster et al, J Consult Clin Psychol, 1997.

28. Defined Weights % Reduction Dream 38% Happy 31% Acceptable 25%
Disappointed
17%

29. % Achieving Defined Weights
at Week 48*
*(N = 45) Weight loss: kg
Happy
Acceptable 9%
24%
Dream = 0%
20%
47%
Did not reach
Disappointed Weight
Disappointed
Foster et al, J Consult Clin Psychol, 1997.

30. Helping Patients Accept More Modest Weight Losses
Be clear about what treatment can do and what it cannot do
Discuss biological limits
Focus on non-weight outcomes

31. “As with any chronic illness, we rarely have an opportunity to cure
“As with any chronic illness, we rarely have an opportunity to cure. But we do have an opportunity to treat the patient with respect. Such an experience may be the greatest gift that a doctor can give an obese patient; it compares favorably with the modest benefits of our program of weight reduction.”
Albert J. Stunkard, MD
Obesity: Theory and Therapy, 1993; Lippincott-Raven.