How to avoid ‘fat shaming’ patients for more effective conversations around obesity

From the humble stethoscope to the most sophisticated gene-editing technology, health care professionals today have a remarkable range of tools at their disposal.

But perhaps the most powerful tool for primary care providers is their oldest: their words.

A widely cited review of doctor-patient communication undertaken by Jennifer Fong Ha, MBBS (Hons) Dip Surg Anat, and Nancy Longnecker, PhD, both from the University of Western Australia, found that effective communication between provider and patient is essential to achieve high-quality health care. And nowhere is this more important than when broaching sensitive subjects like obesity and overweight.

According to the Obesity Medicine Association (OMA), obesity affects over 236 other medical conditions. But most clinicians spend their time treating the complications of obesity while ignoring the root cause of these complications: excess adiposity and metabolic dysfunction. Treating obesity directly would enable providers to improve or resolve complications that have already arisen (often with fewer medications), or better yet, prevent the development of these complications to begin with.

I would argue that the current model of treating the complications of obesity while ignoring the underlying cause is not sustainable. It does not sufficiently improve the health and quality of life of the patient.

It is time for providers to become educated in the disease of obesity and to start treating it as they would any other medical condition. Treatment of obesity may include the use of anti-obesity medications or other evidence-based therapies such as bariatric surgery or devices, as an adjunct to lifestyle changes. This has to begin with conversations that use patient-centered language. Here are some considerations to keep in mind before beginning.

Conversations about weight need to be initiated with care and respect

Choosing the appropriate time and circumstances is critical when initiating a conversation about obesity with patients. A good opportunity to discuss weight might be during an annual physical or well exam, or when discussing a medical condition that is affected by obesity, such as type 2 diabetes, hypertension, dyslipidemia, polycystic ovary syndrome, obstructive sleep apnea, GERD, joint pain, or numerous other medical concerns.

It is important, however, not to immediately attribute a patient’s complaints to weight. Instead, the clinician should assess their medical condition just as they would in a patient with normal weight. For example, if a patient presents with knee pain, provide the usual care for this complaint, including ordering any necessary imaging. Ask about potential causes or triggers for the knee pain before assuming the cause is obesity or overweight.

If the complaint has been thoroughly investigated and overweight is found to likely be a contributing factor, the provider can respectfully ask the patient if they are open to having a discussion around weight. Without blaming or shaming the patient, explain that weight regulation is much more complex than “eating less and moving more.” At this point, you can offer to provide evidence-based help and, if the patient agrees, you can schedule a follow-up appointment to specifically discuss weight.

Engaging patients with motivational interviewing techniques

Research suggests that enlisting patients as partners in improving their health can be effective in enhancing weight loss. Patients need to feel empowered when it comes to their health and being engaged in the conversation with their provider plays an important role in this.

Giving advice without asking patients what their barriers might be and without soliciting possible solutions leaves them feeling that the provider does not understand — or worse, does not care about — their circumstances or needs, and thus cannot really help them. Instead, using motivational interviewing techniques, such as asking open-ended questions rather than yes/no questions, can help patients feel more engaged when discussing their health.

These open-ended questions allow the patient to express their thoughts and their reasoning, which can then give the provider much more insight into the patient’s perspective. But for this to work, providers need to take the time to listen to their patients. While the health care provider may be the expert in medicine, the patient is the expert on themselves. And they are much more likely to follow advice if they are part of the decision-making process, rather than being told what to do.

Five tips for opening up effective conversations with patients

Ask permission

The first step a health care provider can take is to ask permission to discuss a health topic, especially if it is a topic that may be sensitive to the patient. For example, a provider can say, “Nutrition plays an important role in diabetes management. Is it okay if we discuss your nutrition today?” By asking permission, the health care professional is showing respect for the patient’s autonomy and agency in discussing their own health.

Respect the patient’s response

If the patient does not give permission to talk about a particular topic, the provider should respect that decision. The provider may offer to provide the patient with additional resources on the topic and reassure them that whenever they are ready to discuss the topic, the door is open. If the patient does give permission, the provider should once again use motivational interviewing and ask open-ended questions. For example, a provider could ask: “How is your weight affecting your health and quality of life?” or “How do you feel about your alcohol consumption?” The tone should convey empathy and a genuine desire to help the patient.

Avoid giving directions

When it comes to encouraging health behavior change, especially with complex behaviors such as eating or physical activity, health care providers should avoid the “righting reflex,” which is telling the patient what to do. Instead, they should try to engage the patient in the decision-making process and elicit possible solutions. If the patient does not have any ideas, the provider can offer two or three options and let the patient decide which one seems like the best fit. Once a decision has been made, the provider should summarize the plan and verify that the patient feels confident in their ability to follow through.

Pay close attention to the words you use

The language used to discuss obesity is incredibly important to avoid “fat shaming.” In general, practitioners should never label a patient with their disease but instead use people-first language. In the case of obesity, this means using phrases like “a person with obesity” or “a person affected by obesity” vs. “an obese person.” The Obesity Action Coalition has created a very helpful one-page handout on the use of people-first language for obesity, which can be accessed here.

Reconsider the diagnostic language of obesity

Health care professionals use the diagnostic term “obesity” to recognize this as a disease. Patients, however, may not be comfortable using “obesity” or even with the word “disease,” due the bias and stigma associated with these terms. When initiating a conversation around weight, consider using terms like “weight,” “excess weight” and “elevated BMI.” Keep the focus of the discussion on health and consider using terms like “chronic medical condition” vs. “disease.” As you educate the patient about the complexities of weight and appetite regulation, you can ease into the diagnostic term of “obesity.” You can also ask patients which words and terms they would prefer and acknowledge that obesity and weight management are fraught with bias and stigma.

Above all, keep in mind that the patient is not to blame for their weight — obesity is a complex medical condition with numerous causes, many of which go beyond lifestyle choices. Despite this, many patients have internalized weight bias and blame themselves for their obesity. Because they feel that it is entirely their responsibility to manage their weight, patients will often avoid bringing up the painful topic with their providers.

When providers let patients know that there is much more to obesity management than simply eating less and moving more, they enable patients to feel — perhaps for the first time — a sense of relief and hope. And this can help patients take the first steps on their journey to better health.

Want to learn more about how to treat obesity across the lifespan? The Obesity Medicine Association's fall conference, Sept. 23-26, is the leading medical conference providing clinical education for health care providers on how to effectively individualize obesity management in your patient population. This year’s conference will be in-person as well as feature a virtual option. Register here. And to stay ahead of the curve in the prevention, treatment and reversal of the disease of obesity, become a member of the Obesity Medicine Association.

References:

Armstrong MJ, et al. Obes Rev. 2011;doi:10.1111/j.1467-789X.2011.00892.x.

Emmons KM, Rollnick S. Am J Prev Med. 2001;doi:10.1016/s0749-3797(00)00254-3.

Ha JF, Longnecker N. Ochsner J. 2010;10:38-43.

Obesity Action Coalition. People-first language for obesity. https://www.obesityaction.org/wp-content/uploads/1033162_FirstPersonOne-Pager01_041921.pdf. Accessed June 14, 2021.

Obesity Medicine Association. What is obesity? https://obesitymedicine.org/what-is-obesity/. Accessed June 14, 2021.

Obesity Medicine Association. Diseases related to obesity. https://obesitymedicine.org/diseases-related-to-obesity/. Accessed June 14, 2021.

Obesity Medicine Association. What causes obesity? https://obesitymedicine.org/what-causes-obesity/. Accessed June 14, 2021.