Weight management during checkups

Peggy Howell and her physician have an agreement. They don’t talk about weight loss. Howell, who regularly calls herself fat, doesn’t want to lose weight.

"I’m of a large body size, and I’m of good health,” she said. “If you want to talk about my (dietary) intake based on resolving a health issue, then I’m all for it."

Howell, 67, lives in Las Vegas and is director of public relations for the National Association to Advance Fat Acceptance.

"I think that it’s important to be informed, but if that is done in a way to make people feel bad about themselves or uncomfortable about themselves, then no,” she said.

Some of the most-frequent and most-delicate conversations in primary-care doctors’ offices involve weight. In modern medicine, there’s a push to monitor patients’ body-mass indexes and to talk about being overweight or obese and the links to health problems, including Type 2 diabetes and heart disease. Weight as a risk factor is widely accepted, but figuring out the most-productive way to talk about it (or deeming it off the table, as in Howell’s case) can be tricky and depends on how a patient views his or her weight.

Today’s medical education places a high importance on training doctors for the less-comfortable conversations, said Dr. Nanette Lacuesta, the assistant director of the family-medicine residency program at OhioHealth Riverside Methodist Hospital.

Lacuesta said practicing for tough talks makes for smoother real-life scenarios. She has found — and tells new doctors — that open-ended questions work well. An example: “How do you feel about your weight?”

“Then we try to get them to tell us what they’re willing to do,” she said. “Hopefully, you already laid the groundwork that you have their best interest in mind.”

Prescriptive (and often generic) advice — “You need to lose 40 pounds,” “You need to stop eating unhealthy food,” “You have to exercise” — tends to not do patients much good.

She also suggested that patients who want their doctor’s help with losing weight make an appointment dedicated to that. Often, the subject comes up at the end of another visit, and there isn’t time to adequately offer help, Lacuesta said.

“The most-important thing is that it’s patient-centered,” Lacuesta said. “My inclination is to connect it with the health risks such as diabetes, hypertension and stroke. You have to think, ‘ What is going to make it important to them?’  ”

Dr. Larry Swanner, a family-medicine specialist and vice president of medical affairs at Mount Carmel West hospital, said the nature of weight conversations varies greatly depending on the physician and the patient.

“Some people don’t want to talk about it unless it’s absolutely necessary,” he said. “Society sometimes makes people feel like failures, like they have a deficiency of character or can’t resist temptation, and that’s not it.”

Swanner said the conversations should happen for the sake of good preventive medicine, but they must come with compassion and empathy. “It doesn’t do any good to shake your finger at them and tell them they’ve got to do better.”

Aside from the fear of offending patients, some doctors avoid conversations about weight because they feel ill-equipped to offer constructive guidance on how to help.

“There’s no one clear, sure-fire cure for this problem. It’s not an easy problem to address,” Swanner said.

Dr. Randy Wexler, a family-medicine specialist with Ohio State University’s Wexner Medical Center, said an increasing emphasis on patient satisfaction in health care can make it even less-desirable to step into conversations that doctors know might be volatile, Wexler said.

“Patients sometimes get upset when we bring up things like that. I’ve had a patient demand to have obesity removed from their chart,” he said. “It doesn’t take many of them to make you gun-shy.”

When he does bring up weight, it’s not on a first visit. He waits until he feels that he has established good rapport and usually looks for an opening, such as mobility problems or high cholesterol.

Howell’s organization has developed guidelines for doctors. For example, it doesn’t want physicians to automatically weigh patients without a compelling reason, it wants them to avoid the word obese, and it doesn’t want them to assume that patients are interested in weight loss.

Howell said she has fielded calls from many people who have been turned away by doctors who don’t want to treat them or would not address their medical concerns beyond assuming that weight loss was the only option.

Lacuesta, of OhioHealth, can see why that could be upsetting. “If I was a patient that was overweight, I can imagine how frustrating it would be to walk in and have your physician assume your weight is responsible for everything that’s going wrong with you,” she said.

Resources: http://www.dispatch.com/content/stories/local/2014/05/25/your-health/touchy-topic.html