The Clinicians' Guide on Talking to Patients About Obesity

Assess Obesity Objectively, Not Judgmentally

Then, give patients with obesity the support, resources, referrals, and choices they need.

With Rebecca Puhl PhDElena Christofides MD, FACE, and Scott Isaacs MD, FACE

Obesity Treatments

Obesity is a disease and a chronic health condition, not a lifestyle, a moral failing, or a choice. Though it is undeniable that diet and exercise are essential to weight management for any person, research also increasingly shows that for many patients with obesity, lifestyle interventions are not a sufficient course of treatment or path to achieving or sustaining relevant weight loss.

It is a popular misconception in both the medical and lay communities that weight loss medications should be a second-line treatment, prescribed only after all lifestyle modifications have failed. This is simply not the case. Current clinical guidelines recommend adjunctive pharmacotherapy for patients who have a BMI higher than thirty, and for those who have a BMI higher than 27 with coexisting conditions that often accompany obesity, such as type 2 diabetes, hypertension, nonalcoholic fatty liver disease, insulin resistance, and other comorbidities which can worsen when a patient with obesity is unable to lose or stop gaining weight using lifestyle modifications alone.

Why BMI Is Not Accurate

That said, like weight, BMI is a rough approximation of overall health. "The fact is that BMI is a number that doesn't take anything else into account other than the raw weight that gravity is exerting on your body mass. Fortunately, obesity management and our understanding of the health consequences of obesity are much more nuanced than that at this point," says diabetes and metabolism specialist Elena Christofides MD, FACE. "As clinicians, we should recognize that central adiposity or visceral adiposity, where some patients hold weight in the middle of the body around the internal organs, is dysfunctional and can contribute disproportionately to health consequences. That central fat core is not represented in a number like weight or BMI."

"If a clinician is trying to distinguish whether a patient is healthy or unhealthy, there are other signs that a patient who is in a certain weight or BMI range may be developing symptoms and comorbidities of obesity, such as type two diabetes, high triglycerides, hypertension, blood pressure irregularities, elevated uric acid or gout, and osteoarthritis of the knees and the hips, all of which are known to be symptoms associated with carrying excess weight. But it isn't weight that I look to as an indicator of obesity," says Dr. Christofides. "These benchmarks, tests, and measures of inflammation are the signs and symptoms that indicate a patient may need treatment beyond a recommendation for lifestyle changes or a connection to a nutritionist or physical therapist."

If a patient has these or any other underlying health problems associated with obesity, clinicians should recommend that patient to an endocrinologist or obesity specialist who is experienced in treating obesity and can begin to discuss options for treatment such as medication beyond lifestyle modifications.

Perform a Thorough Medical Assessment

Clinicians are advised to do a full assessment of a patient who is diagnosed with obesity as a result of any of the health issues mentioned above or other co-occurring conditions. 

Step 1: Gather Information About Habits and Behavior

Ask the patient:

  • What time do you wake up?
  • What time do you go to sleep? 
  • What time is your first meal and what does it consist of?
  • What do you do and eat on an average day?
  • What snacks and drinks do you regularly consume?
  • What are the drivers of your lifestyle, including activities and acquaintances?
  • Where do you turn for comfort and support?

Step 2: Review previous diagnoses and medical history

Step 3: Take a full inventory of existing medications and supplements

Present Weight Loss Treatment Options 

"Patients often come to me after their primary care physician has shamed them or implied that they were being dishonest about following their exercise or diet plan," says Scott Isaacs MD, FACE, FACP. "As an obesity specialist, the first thing I say to them is that I believe them. I know that I can test two patients' metabolic rates, and they will be completely different. A patient who was 300 pounds, has already lost 50, and is finding it difficult to lose 50 more is going to have a completely different and much slower metabolic rate than a patient who is 300 pounds but recently gained 50 pounds. Those of us who understand that obesity is a disease know that a person dealing with it can have a completely different metabolic rate than a person who is not or hasn't been for as long a period of time."

After performing an assessment, clinicians should present any options for treatment that have been deemed safe and possibly beneficial to the patient's health and weight management, then discuss them with the patient as they would options for treatment for any other disease.

"The next thing I do after I present treatment options to a patient is temper expectations. Patients with obesity have been conditioned by previous physicians who are not endocrinologists or obesity specialists to believe that they need to lose what is often an unrealistically large amount of weight as quickly as possible," says Dr. Isaacs. "I bring out my graphs and show them how much weight they can realistically expect to lose on each type of treatment and explain that even a loss of 5-10% can have a huge impact on their health."

Average Body-Weight Percentage Patients With Obesity Can Expect To Lose on Different Types of Treatments

  • Lifestyle modifications: 2-3%
  • Existing weight loss medications: 5-7.5%
  • Surgery: 25-30%

Develop a Weight Loss Treatment Plan in Collaboration with the Patient

Clinicians should be mindful that patients dealing with obesity are likely to have a complicated medical history, and the decision of whether to try an adjunctive pharmacotherapy or consider surgery must come from them after considering all of the options and variables in play in their specific case on their own timeline.

Contrary to common misinformation, patients with obesity who undergo pharmacological treatment or surgery are not doing so in place of lifestyle modifications of diet and exercise, but in addition to those and other healthy behavioral changes to have the best chance possible at sustainable weight loss and better health.

As with any other disease or health condition, patients with obesity should be given every opportunity and type of care that can improve their health and quality of life that they elect to, including treatments and lifestyle modifications, but also referrals to nutritionists, diabetes educators, therapists, trainers, and other professionals and resources to help support them in what is often a long and complicated journey to better health.

Patients considering surgery or medications that primary care physicians and other health care practitioners aren't familiar with should be referred to endocrinologists and obesity specialists when possible before beginning any new course of treatment for obesity to receive the best standard of care, as obesity is a difficult condition to treat with a high rate of weight regain over time after every type of treatment.

Referring patients seeking treatment for obesity or who would like to lose weight for medical reasons to a specialist and other resources for their condition increases their chances of getting the care they need to sustain a healthy weight and thrive.

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