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Q&A: How to engage patients in managing obesity

As a potential risk factor for conditions such as heart disease, stroke and diabetes, obesity is an aspect of overall health that should be monitored as part of routine primary care. When excess weight is combined with other risk factors such as high cholesterol, elevated BP, or elevated blood glucose, addressing and treating the obesity is a heightened priority.

However, introducing the topic of obesity in a primary care setting can be challenging. The clinician should begin the conversation in a manner that engages the patient, rather than inadvertently humiliating, judging or alarming the patient, as these approaches are alienating.

Additionally, primary care physicians should have adequate knowledge of obesity treatment strategies to engage the patient in an informed discussion about the full range of available options, and know when referral to an obesity specialist is warranted.

Scott Kahan

Healio Internal Medicine spoke with Scott Kahan, MD, MPH, from Johns Hopkins Bloomberg School of Public Health and director of the National Center for Weight and Wellness, about how the PCP can establish themselves as a compassionate, knowledgeable, and helpful resource in managing a patient’s obesity.

Question: How do you broach the topic of obesity with appropriate patients?

Answer: Most importantly, appreciate how sensitive and how deep an issue weight and obesity are for most of our patients, particularly those with severe obesity. Within that context, try to build an approach where you feel comfortable bringing it up, but also feel comfortable that your patient will interpret your interest in helping them with their health, rather than demeaning them.

It is important for physicians to recognize that many patients, particularly those with severe obesity, have had such poor experiences in the health care system. Weight is a sensitive issue, and patients may carry “baggage” from being teased as a child or being excluded on the playground, as well as prior negative experiences in the healthcare system. It is vital for clinicians to enter the discussion with an insight of how sensitive people are about this issue.

First, try not to use words that can be perceived as offensive or demotivating. Quite simply, ‘obese’ is a term that most people do not like to hear. It’s easy for us to just tweak that word a little bit and it will go from something that can trigger sensitivity in many people to something that’s more neutral, or even motivating. For example, instead of saying, “You’re obese,” you could say, “You have obesity.” An even more neutral phrasing would be, “You’re carrying some excess weight.” I personally like to use that term — weight. I use it in lots of different ways; sometimes, grammatically, it doesn’t seem right, but it’s least likely to turn a patient off. When talking to patients who have obesity, I’m talking to them about their “challenges with weight,” rather than “being obese.” It’s sort of a euphemism, but it’s very helpful to ease patients into a discussion about how to move forward.

The second thing I suggest is giving patients the power in the discussion, given that it’s often a very emotionally charged issue. One way to do that is by asking permission if it’s OK to talk about weight or whether it is the right time to have the conversation. The conversation can go like this: “Since I’ve been seeing you over the past few years, I’ve noticed that your weight has been climbing. We know that weight is associated with lots of health problems. I’ve had some training in how to help patients with weight issues. Would it be okay if we talked about your weight today?”

Even if the patient isn’t interested in talking about it that day, introducing the topic in such a way can set the stage for the next appointment, when they might be more open to it.

Q: Are ‘scare tactics’ ever effective?

A: I don’t believe in scare tactics. Sometimes, external motivations like scare tactics can have short-lived effects, but it’s rarely more than short-lived, if it works at all. The drawbacks of scare tactics far outweigh any potential short-lived benefits. Those drawbacks include making the patient feel bad or guilty, and pushing the patient away. In contrast, helping patients build their internal motivation for change – where they feel energized about making a behavioral change – is much more productive, especially over the long term.

Q: What are your first-tier recommendations for patients with obesity?

A: The first, second and third step is to begin the conversation. It opens up many opportunities for counseling, support, guidance and referral, if necessary.

Once you’ve initiated the conversation, try to meet them where they are. For patients who have never tried to manage their weight or who have never engaged formally with a physician, dietitian or weight-loss program, there’s going to be a lot of “low-hanging fruits” – that is, opportunities for simple, meaningful changes.

Then, discussion with the patient will likely lead to many other targets that you can work on together. For example, a patient may drink a lot of soda or do a lot of emotional eating; these then become priorities to start to address. Talk with the patient, just like we do in other areas of medicine, where you’re learning about what may factor in to the patient’s given presentation and then addressing it as appropriate.

If you have a patient who has already tried many times to lose weight, seen dietitian after dietitian, been to Weight Watchers and Jenny Craig and beyond, then in a primary care setting you might not be able to add much beyond what they have already learned, unless you have training in obesity. In those cases, you can support the patient and consider referral to a resource that can offer more time and expertise. This could be an obesity medicine physician, like myself, at an evidence-based obesity treatment clinic. Many patients have been to a commercial program, but not to a formal, science-based clinic. In some cases, you may refer the patient to a bariatric surgeon. It depends on where the patient is coming from and what they’ve already tried in the past.

Q: What should PCPs know about pharmacologic interventions for weight loss to facilitate their discussions with patients?

A: I think doctors traditionally have many of the same misunderstandings about pharmacologic therapy for obesity as lay people do. It’s important for them to learn about the options, the indications, and how to use them, or at least know where to refer patients to.
Currently, we have several helpful medications. Five medications are approved for long-term use, and four are approved for short-term use. All of the long-term medications have good data on long-term efficacy and safety. They all work in different ways.
It’s important to learn about the available medications and to be able to counsel your patients on the different options to help them choose the most appropriate option. It’s also perfectly acceptable to refer patients to an obesity specialist in the area to discuss pharmacologic options, depending on the clinician’s level of comfort.

Q: Can you discuss the medications currently approved for long-term use?

A: There are five medications approved for long-term use: combination extended-release topiramate and low-dose phentermine (Qsymia, Vivus); lorcaserin (Belviq, Eisai/Arena); combination extended-release naltrexone and extended-release bupropion (Contrave, Orexigen); liraglutide (Saxenda, Novo Nordisk); and orlistat (Xenical, Roche; Alli, GlaxoSmithKline). The latter is an older medication.

These medications are effective in patients who may have struggled with their weight in the past. Some lower appetite or cravings, others increase satiety. They can be used long-term to bring weight down and keep it off, much the same as BP medication that helps to bring BP down and continue to keep it down. If the patient has ongoing counseling and is actively working at making behavioral changes in addition to taking the medications, there are much better outcomes. The medications also help the patient make those lifestyle changes. You get almost twice as much weight loss when those two things are in place.

Q: What should PCPs tell patients who have questions about bariatric surgery?

A: Again, I think many PCPs have a lot of the same areas of misunderstanding around bariatric surgery as lay people. Which is to say, many doctors think bariatric surgery should be off the table. They may think it’s not appropriate, or not safe, or that everybody regains their weight. Then there are other doctors, and patients, who may believe it’s the answer to everything. While neither of these extremes are true, bariatric surgery is a very valuable and well-studied treatment for appropriate patients. We’re talking about patients with severe obesity (75 to 100 lb. overweight or more).

If PCPs can learn more about bariatric surgery so they can discuss the basics with their patient, that can be helpful. Having a good referral to a bariatric surgery clinic in the area is going to be very important.

Q: What should PCPs keep in mind about a patient’s overall health when treating patients who are taking weight loss medications?

A: In general, obesity is a health issue, rather than a size issue. If someone comes to see me and they’re carrying around a lot of extra weight, but they’re happy, they’re healthy and they don’t have diabetes or high cholesterol, etc., treating that weight may be less of a priority. It may be more of a priority for those patients to try to just keep more weight from coming on, and of course to continue their healthful habits that are already in place. On the other hand, even if they’re only a little bit overweight, but they have diabetes or other significant health problems or risk factors associated with their weight, then we want to be more aggressive. It’s the patients who have more weight-related health problems where we want to prioritize escalated treatment with medication or surgery when appropriate. Of course, as with any medication or treatment, you need to evaluate for possible contraindications, but more often than not patients do not have contraindications.

Q: What does a PCP need to consider in patients who have undergone weight loss surgery and have returned to the practice for routine care?

A: First and foremost, remember that bariatric surgery is a very valuable tool, but it is not a cure. Patients need long-term, ongoing support and counseling, even after surgery. The PCP is one of the resources that can offer that support and counseling. In general, most patients should be followed by their surgeon in the immediate postoperative period, and for at least 1 year after surgery. If the surgeon isn’t requiring follow-up, the PCP can advocate for the patient to ensure better follow-up after surgery. Beyond the initial period after surgery, patients will need to find additional support, whether at an obesity clinic or a bariatric surgery support group or the like. PCPs can also play a valuable role in supporting patients after surgery and over the long term.

One nugget of information to consider: If patients undergo bypass surgery, it’s helpful to know that extended-release medications may be less effective, because part of the bowel has been cut out and there’s not as much absorptive capacity. The PCP should be aware of that. Occasionally, because of differences in absorption, medications may need to be adjusted after surgery. This is handled on a case-by-case basis. Often, this means lowering or stopping medications for BP, diabetes, etc. One of the real benefits of bariatric surgery is that a patient can stop many of these medications.

The big picture is, the PCP should continue to monitor patients closely to make sure everything is going well. – by Jennifer Byrne

For more information:

Scott Kahan, MD, MPH, can be reached at 1020 19th St. NW, Suite 450, Washington, D.C. 20036; email: kahan@jhu.edu.

Disclosure: Kahan reports being a consultant for Novo Nordisk, Takeda and Orexigen.