GPs' Discussion of Weight With Patients Rare, and Mainly Negative

Pam Harrison

December 09, 2019

Overweight and obese patients not only have few interactions with physicians about their weight but the encounters they do have are largely negative experiences, a new systematic review of patients' perspectives on the subject reveals.

"The overwhelming theme [from this review] was that interactions between patients and doctors about being overweight and weight loss were rare, [and] for participants, not discussing these issues had several meanings...the most profound [being] that people who were overweight felt stigmatized and assumed others, including the doctor, were judging them negatively," write Thanusha Ananthakumar, MD, University of Oxford, UK, and colleagues in their article, published online December 2 in Clinical Obesity.

"Many clinicians fear that if they discuss weight with patients, some will find this unwelcome or offensive," the researchers hypothesize

They advise that physicians start a discussion with the assumption that a person may well already be taking action to lose weight and that what is required is guidance and encouragement.

And clinicians should note that a person's harshest critic of weight status is usually themselves and therefore avoid making "statements that may be interpreted as a judgment carrying moral connotations."

Raise the Subject of Weight, but Address It Sensitively

In their review, the authors included 21 qualitative studies in which people with overweight or obesity had consulted a primary care physician and given their reactions to consultations during which weight could have been or was discussed.

Participants in all but one study had a body mass index (BMI) in excess of 25 kg/m2 and in most studies, it was in excess of 30 kg/m2, the investigators note.

When the issue of weight was not discussed, some patients indicated that they felt their healthcare providers' silence suggested they were not worthy of their time, or that being overweight or obese was not a serious health issue.

"Others regarded it as a failure of the doctors' duty to warn patients of future health problems related to excess weight," Ananthakumar and colleagues observe.

But on the other hand, there was uncertainty and mixed views about whose responsibility it was to bring up weight in a consultation.

A few respondents thought that their physician should ask permission to discuss their weight before initiating a conversion about it — even though some participants indicated they would have liked their physician to actually start a discussion about it, at least in part because they were ashamed of being overweight and unable to lose the weight.

"Where it was mentioned, most participants reacted negatively to doctors describing them as 'obese'," the authors note.

In fact, when described as "obese", "in some cases, the word demotivated participants to lose weight because they felt hopeless," they explain.

For many patients, even the tone of voice and the manner in which weight was raised by the physician created negative feelings, again undermining their motivation to lose weight.

"A recurrent theme across studies was that doctors often assumed a person who was overweight must have an unhealthy diet," the investigators write, "[and] these assumptions reflected a common belief that people who are overweight eat a lot of 'junk food' and are not physically active."

Physicians also sometimes offered advice about weight loss that patients felt was banal, implying that the patient was either not trying to look after themselves or they were too stupid to not have already realized what physicians themselves were suggesting and already done something about it.

Doctors Assume Symptoms Are Weight-Related Without Due Diligence

Many patients also reported that they visited their doctor with symptoms that may have been related to being overweight or obese but their physician immediately presumed their symptoms were weight-related without taking a history or doing a physical exam.

"This left participants feeling dismissed and anxious that a more serious cause for their symptoms might go undetected," the authors point out.

By so doing, patients also felt they had been denied a legitimate treatment and were instead being made to suffer in a punitive manner because of their weight.

"Clinicians should take care when linking weight to a presenting medical issue and discuss weight loss as one of a range of treatment strategies rather than presenting excess weight as the cause of the problem and weight loss as the only cure," the authors emphasize.

When physicians did address the health risks of being overweight or obese, nobody appreciated being scolded or made to feel personally responsible for their presumed weight-related symptoms, as this attitude reflects an all-too-common belief that obesity is a failure of willpower, the authors explain.

On the positive side, patients said that when they trusted their doctor, discussions about being overweight and weight loss were easier and that trusting their physician motivated them to act on their doctors' advice.

"People in society, including many clinicians, hold stigmatizing views of people who are overweight, believing them to be generally less capable and weak-willed," Ananthakumar and colleagues observe.

"And patients with overweight internalize weight stigma, sensitizing them to clues that clinicians are judging them negatively, even if weight is not discussed," they add.

This is in direct contrast to the fact that most people who are overweight are trying hard to lose that weight and, over the short-term at least, are even likely to lose some weight.

"It may [thus] be helpful to start a discussion with the assumption that a person may well be taking action and that what is required is guidance and encouragement towards more effective interventions," the authors suggest.

Clinicians should also remember that the harshest critic of a patient's weight status is likely the patient themselves and avoid statements they may perceive as judgmental.

"Weight loss discussions are more likely to be successful when they involve a trusted clinician who gives time to share options for weight loss in a nonjudgmental manner," they conclude.

Clin Obes. Published online December 2, 2019. Full text

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