Breaking the Silence on Obesity

Abstract

Obesity is a significant global public health concern, and health care providers play a crucial role in addressing it by offering healthy lifestyle counseling and weight management support. Evidence demonstrates that even brief counseling on healthy behaviors can lead to meaningful changes and sustained weight management. However, weight consultations are often underutilized in primary care due to various barriers, including biases against patients with obesity, misconception of physicians with obesity, or concerns about stigmatizing them by initiating discussions about weight. This paper explores the impact of biases, misconceptions, and stigma on the communication and treatment of patients with obesity and proposes strategies to overcome these challenges. Practical solutions include fostering inclusive health care environments for individuals of all body sizes and utilizing the 5A model (Ask, Assess, Advise, Agree, Assist) to guide respectful and effective weight management conversations.

“Many patients with overweight or obesity can benefit from even brief counseling, regardless of their immediate desire to lose weight.”

Introduction

Obesity is a growing health problem, with more than 42.4% of adults in the United States (US) affected. ¹ The physician-patient relationship plays a crucial role in addressing this problem, as frequent clinical interactions offer opportunities for lifestyle counseling, such as promotion of healthy eating and physical activity, for sustained weight loss.^2-6 For instance, in this issue, Jackson, Stickler, Biddle, Trilk ⁷ discussed that 73% of women who received nutritional counseling during pregnancy reported modifying their behaviors based on the advice provided by their health care provider. This finding underscores the pivotal role health care providers play in counseling patients on weight management and promoting healthier lifestyles.

While primary care providers can effectively counsel patients on healthy diets and physical activity to achieve modest weight loss, they rarely provide weight management counseling to their patients.^8,9 This may be due to multiple barriers including time constraints and lack of appropriate training in weight management counseling. ¹⁰ Additionally, the discomfort surrounding the sensitive nature of discussing weight is a significant challenge.^2,9,11,12 Evidence suggests that patients with overweight or obesity are reluctant to initiate conversations about their weight, viewing it as the health care provider’s responsibility to raise the issue. ¹³ Conversely, health care providers express concerns about broaching the topic, fearing negative reactions from patients, including frustration and anger when presenting complaints are attributed to weight. ¹⁴ This dilemma results in missed opportunities to address a critical public health concern. In this commentary, we explore the issues surrounding healthy lifestyle counseling for weight management and present practical strategies to help health care providers navigate these conversations more effectively.

Engaging in a Difficult Conversation

Many patients with overweight or obesity can benefit from even brief counseling, regardless of their immediate desire to lose weight. Evidence demonstrates that short conversations—lasting just 3 to 5 minutes—during routine visits can lead to significant behavioral changes. ⁹ For example, patients advised by their health care professionals to lose weight are 3 times more likely to attempt weight loss than those who do not receive such advice. ⁸ Counseling on healthy eating and physical activity in primary care settings has also been shown to result in modest improvement in dietary habits and physical activity.^15-17 Recognizing these benefits, many primary care physicians view addressing obesity as part of their role. ¹⁸ However, studies indicate that only about one-third of individuals with overweight or obesity receive weight-loss counseling from their physicians. ¹⁹ The lack of conversations about obesity in health care settings is a complex issue with several contributing factors.

One potential reason for the absence of these discussions can be the bias held by health care providers that people with obesity are responsible for their weight.^4,11,20 Obesity is a highly stigmatized condition, often resulting in negative attitudes and discriminatory behavior. ¹² Research shows that 69% of individuals with obesity have reported experiencing weight bias from physicians, and this bias becomes more prevalent with increasing severity of obesity. ²¹ Health care providers may perceive individuals with obesity as noncompliant, overindulgent, lazy, or unsuccessful. ¹¹ These perceptions can hinder providers from offering lifestyle counseling, as they may assume that patients with obesity will not adhere to their recommendations. Conversely, health care providers with overweight and obesity may avoid providing weight-loss counseling due to concerns about being perceived as hypocrites for not following their own advice. For instance, physicians with healthy weight are more likely to provide weight-loss counseling to their patients than physicians with overweight and obesity. ²² Physicians with overweight and obese reported a lack confidence in providing their patients diet or exercise counseling, whereas physicians with healthy weight feel more assured in their ability to impact patients and serve as role models. ²² Such biases and misconceptions can severely limit patients’ access to necessary treatments.

Fear of stigmatization or discomfort in addressing weight-related issues can be another reason that prevent health care providers from initiating the discussion regarding patients’ weight status.^23,24 Providers may hesitate due to concerns about damaging the patient-provider relationship or causing emotional distress. ²⁵ However, this is very risky as patients may interpret this lack of dialogue as an indication that their weight is not a significant concern, further diminishing the likelihood of receiving appropriate guidance.^25,26 Whether it is a bias or discomfort in initiating talk, health care providers must overcome these barriers to deliver effective counseling on healthy lifestyle changes. ⁴ Therefore, health care providers need established tools and strategies to overcome bias and stigmatization in talking about obesity.

Strategies for Healthy Lifestyle and Weight Management Consultation

The first step in weight counseling can start with creating a welcoming environment, which is essential to ensure patients feel comfortable and respected.^27,28 This includes equipment that accommodates diverse body sizes (e.g., sturdy scales, examination tables with higher weight capacities, larger blood pressure cuffs) and waiting areas with seating options for various needs (e.g., armless chairs, wider seats, supportive couches). These minor adjustments foster an inclusive atmosphere, enhancing patient care and overall experience.

Many primary care physicians struggle to initiate conversations about their patients’ weight. ²⁹ To address this challenge, an evidence-based 5A model (Ask, Assess, Advise, Agree, Assist) was developed to help guide effective weight management discussions.^5,30,31 The 5A model is an effective behavior-change counseling model. ³² The first step in this model involves “asking permission” to discuss the topic of weight. It is essential to approach weight and discussions with respect and empathy, as an immediate focus on weight may make some patients feel their primary health concerns are being overlooked. ³³ Evidence suggests that patients are more receptive to counseling when clinicians frame weight as a medical issue or as a contributing factor to other health problems. ² Providers can ask permission by summarizing whole picture such as, “Your body mass index, waist circumference, family history and fasting glucose levels suggest to me that you are at risk for type II diabetes. Without changes in diet and lifestyle you may develop type II diabetes within a few years. Can we talk about how you can change those behaviors?” If the patient declines, their decision should be respected, and health care providers can ask if revisiting the topic in the future would be acceptable. If the patient agrees, health care providers can proceed with sensitivity to facilitate the conversation.^9,28

The 5A model highlights the importance of accurately “assessing” a patient’s weight status using tools like BMI and waist circumference. ⁵ However, a chart review found that while health care providers understood obesity assessment, BMI was rarely documented in admission or discharge notes. ³⁴  Weight status, such as an elevated BMI, serves as a critical screening tool that should prompt a deeper evaluation of lifestyle behaviors, including diet, physical activity, and sleep patterns. Without proper recognition, effective treatment is unlikely. ⁴ Therefore, understanding and using screening tools for obesity recommended by the US Preventive Services Task Force ³⁵ is crucial step to effective weight and lifestyle consultation.

“Advising” patients on diet, and physical activity and helping to motivate them to make lifestyle changes is essential part of the weight management, as these behaviors are key contributors to overall health. ³⁶ Primary care providers can start the conversation by discussing the health benefits of diet and physical activity, followed by questions such as, “What are your eating habits? What kinds of foods and drinks do you consume on a typical day?” and “What do you currently do to stay active? Would you like to incorporate more physical activity into your routine?”^5,28 These conversations can evolve into goal-setting for lifestyle changes. ³⁷ The key is for both the patient and practitioner to “agree” on realistic, achievable short-term and long-term goals, considering the patient’s individual circumstances.^5,36 Given the time constraints, a referral to specialists such as dietitians, nurse practitioners, physician assistants, or health psychologists—who have the necessary training, expertise, and availability—can be a strategy for advising patients. Lastly, consistent follow-ups are important to “assist” patients in overcoming challenges and maintaining progress on the agreed-upon goals.^5,28 Moreover, those regular follow-up appointments can help show the commitment of practitioners and keep patients motivated and on track. ²⁸

Conclusion

Primary care providers are in a unique position to offer counseling on healthy lifestyles that can lead to sustained weight management for patients. However, they are less likely to provide such counseling during patient visits due to biases, including the belief that people with obesity are solely responsible for their weight, misconceptions of physicians with obesity, or fear of stigmatizing patients by discussing this sensitive topic. Overcoming bias, misconceptions, and stigma is essential to improving patient health and well-being. Creating a welcoming environment for all body sizes and using an evidence-based 5A model (Ask, Assess, Advise, Agree, Assist) to initiate discussions with respect and empathy can help health care providers address obesity more effectively and break the silence surrounding it.