How to Talk About Obesity

A thoughtful article just published in the Journal of the American Medical Association compares the process of building proficiency in patient communication with surgery: both require a methodical approach that includes training, study, preparation, practice, and continual attention to improvement. Yet, while we intuitively appreciate the need to systematically learn and practice the mechanics of surgical procedures, we don't put the same emphasis on building and refining patient communication skills, especially when it comes to the complex subject of obesity.

Most health care providers recoil when they think about counseling patients about obesity. Physicians generally don't talk about obesity with their patients, and despite the rapid increase in obesity prevalence, rates of physician counseling appear to be decreasing, by as much as 25 percent, from 1995 to 2008. One study found that conversations about nutrition last an average of just 55 seconds (perhaps just enough time to admonish patients to "just eat less and exercise more!").

Worse still, I regularly hear from patients that weight conversations with their doctors are often uncomfortable and sometimes off-putting. They describe feeling unheard, dismissed, and shamed. It's so common and counterproductive, that we created a short, dramatized video to demonstrate what not to do when talking to patients about weight:



Indeed, studies show that when feeling shamed and judged about their weight, patients are far less likely to lose weight and often gain more weight over time.

As off-putting as the practices in the video are, and as painful as it is to regularly hear stories from patients documenting these and other inappropriate practices, it's perhaps unfair to blame health care providers -- they have not been properly trained. In research we conducted at George Washington University, we found that 72 percent of primary care physicians reported that they received no training whatsoever in obesity assessment or management. (This finding is likely an underestimate, because several physicians included in the survey were obesity practitioners who nonetheless fit the definition of primary care physician. Fewer than 30 percent of medical schools meet the National Academy of Sciences' minimum recommended hours of education for nutrition and physical activity science (let alone obesity science), and the time devoted to nutrition and physical activity education in medical schools decreased by nearly 15 percent from 2004 to 2009. It's not surprising, then, that many medical residents don't know even the basics of obesity, including definition and diagnosis, let alone treatment.

These numbers resonate. I had only one short lecture on obesity in medical school (just enough to learn to say: "just eat less and exercise more!"). I can't recall any systematic training in the process of communication. And I certainly never learned about communication or behavioral medicine for obesity.

But the good news is that we have a great opportunity to make change by teaching health care providers and trainees about effective communication and counseling for obesity. Studies show that frequent and supportive counseling enhances weight loss. When we discuss weight with patients, there's a several-fold increased likelihood they'll want to address their weight, engage in weight loss behaviors, and successfully lose weight. Medicare and the Affordable Care Act even codified physician counseling for obesity as essential and covered services (though many barriers to use of these determinations still exist).

That's why the STOP Obesity Alliance created a freely-available tool for health care providers to build communication and counseling skills for obesity. Why Weight? A Guide to Discussing Obesity and Health with Your Patients covers how to begin the conversation, what words work best, how to support patients, how to create accommodating office environments, and much more. The website includes videos, handouts, tutorials, and links to other free resources.

Productive patient communication for obesity and health behavior change is critical. Medical schools and training programs for other health care professionals need to include communication and obesity training more explicitly and consistently in their curricula. Practicing clinicians should seek out training opportunities in order to build the skills necessary to help their patients. Without systematic and empathetic patient dialogue, we will never have a real chance of reversing upward obesity trends.

Dr. Scott Kahan is the Director of the National Center for Weight and Wellness, Medical Director of the Strategies to Overcome and Prevent (STOP) Obesity Alliance, and serves on the Board of Directors for the American Board of Obesity Medicine.

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