Q&A: Physicians encouraged to ease guilt, embarrassment in patients with obesity

A new poll suggests the COVID-19 pandemic may have exacerbated the obesity epidemic in the United States.

Prior to the pandemic, the prevalence of obesity in American adults was 42.4%, according to the CDC. The new survey of 545 adults with a BMI of at least 27 kg/m² found that slightly more than half had gained some weight during the pandemic. Of those, almost three in four had gained 10 or more pounds, and half had gained 15 or more pounds.

The poll also revealed that nearly one in three patients have never discussed their weight with a health care professional, and more than half of the respondents said they were “uncomfortable” doing so. Further complicating the issue is that — according to the authors of a recent study in BMC Family Practice — “management of obesity has not been prioritized or managed effectively in primary care settings, [and] fewer than 5% of primary care visits in 2008 were dedicated to obesity.”

Fatima Cody Stanford

Healio Primary Care spoke with Peer Perspective Board Member Fatima Cody Stanford, MD, MPH, FAAP, FACP, FAHA, FAMWA, FTOS, an obesity medicine physician and director of external consultative services for Massachusetts General Hospital’s Weight Center, about how primary care physicians can discuss weight loss with patients. Stanford also discussed a new online resource for patients with obesity, as well as other issues.

Healio Primary Care: Can you please describe the new online resource center for patients who are looking to lose weight?

Stanford: The new resource has been developed in relation to the Why Weight: Communicate campaign. It’s an educational initiative that is being put out to help begin your conversation with your health care provider about your weight. So how do you basically make this happen, how do you begin that conversation in a way that’s productive and helpful? There’s video, there’s conversation starters that are all freely accessible to whoever visits that site to really have that meaningful conversation.

Healio Primary Care: How can PCPs initiate conversations about obesity while avoiding discussions that patients perceive as “fat shaming ”?

Stanford: I think that with primary care physicians and all doctors we have to set up our environment to be safe, warm, supportive and nurturing.

So, one of the key things that you say is, “I’ve noticed you may struggle with your excess weight. Would you like to begin to address that today?” Get a sense of where the patient is. Are they ready to have that conversation — as opposed to assuming they’re ready for that conversation — and if they are ready for that conversation, are they getting a sense of what they would like to address? I think that empowers the patients to have voice and agency to address their obesity or other issues with excess weight.

Healio Primary Care: What are the limitations of using BMI to determine healthy weight? What other factors should PCPs consider when assessing a patient’s weight?

Stanford: BMI is just a calculation that was developed based upon the Metropolitan Life Insurance table back in the 1930s and 1940s, based upon actuarial data. So how many people were dying or getting sick at certain weight statuses, and that’s how they calculated it. The problem with that is it didn’t include key portions of the population. Black individuals like myself, for example, were not included, [and neither were] Hispanic individuals, which make up a sizeable portion of the United States. BMI just considers height and weight. It doesn’t tell me anything about that weight. Is that weight muscle, is it fat? If it is, is it fat that’s stored around organs — what we call visceral adipose tissue? What is it? And so, BMI doesn’t give us the complete picture.

Other things that I use at every single visit with my patients is doing something simple, like using a tape measure to do their waist circumference. When we carry weight around our midsection, it is much more deleterious to our health, and if I carry weight in my butt, which I do, that is actually not harmful. That’s around just muscle tissue and buns. But when it’s in your midsection around important organs like your heart and your liver, this leads to metabolic disease, which leads to a host of health issues. I think BMI is a decent population-wise measure, meaning it can give the general information about the population at large, but when you’re working with an individual patient, you want to focus on just that individual and getting them to that happiest, healthiest weight for them, as opposed to assuming that they have to get to a number, which doesn’t give us a lot of clear information.

Healio Primary Care: How can PCPs help patients set a healthy weight goal and establish a realistic weight-loss journey?

Stanford: So, what I do with my patients, which I think is a good strategy, is first of all, I never give my patients a target weight — and let me tell you, they’ve been asking for over 17, 18 years now: “What weight do you want me to be?” The reason why I don’t do that is because everybody is different, meaning everybody’s body responds differently to interventions, whether it’s changing lifestyle, taking medications or undergoing surgery. And so, I must see what’s the healthiest weight for them. One thing that I do recommend is calculating things like total body weight loss from their initial visit and calculating that over time. What we do know is that if someone loses between 5% to 10% of their body weight, that can have positive outcomes on their health. So that’s looking at a percentage. That 5% to 10% would vary for someone who’s 400 pounds vs. someone who starts at 200 pounds, and that can lead to things like a decrease in blood pressure, improved blood sugar, improved cholesterol status. Those things are real and tangible, and we know that 5% to 10% can help make people move into healthier states regarding not only their obesity, but their other disease processes. For some we even get to 45% — so that’s great, but the goal is having these small measurable goals, starting with the goal of at least 5% initially and then continuing from there.

Healio Primary Care: What are the best strategies that PCPs can share with patients to combat food cravings?

Stanford: I think that one of the best strategies that primary care physicians can utilize is to emphasize the need to consume food that’s not processed. Some of the things that really drive our cravings is the processing of our food; we want our food to look like it looks in nature. I’m going to take on Cheez-It, for example: they don’t look like anything in nature, which means they’re likely processed. We want lean protein, whole grains, fruits and vegetables, whole wheat. When that’s our predominant consumption, it can help with our food cravings.

For those who still struggle, they might need medication much like Contrave, which is a medication that’s used to change some of those cravings. But we have to start with our lifestyle first and then we graduate onto other strategies. And for some, they may even need surgery, and we should recognize that different people will need different treatment strategies, but we want to start at the base of the pyramid with the lifestyle modifications and having that meaningful conversation.

Healio Primary Care: Which prescription weight-loss treatments do you use in practice? What results have you seen with these treatments?

Stanford: As an obesity medicine physician, I use every medication that is currently FDA-approved for the treatment of obesity here the United States. There are a range of therapies. This campaign is being done by the pharmaceutical company Currax, which produces Contrave — a combination of two drugs called bupropion and naltrexone. But in addition to that, I use all the other agents: Qsymia, which is a combination of phentermine and topiramate; and Saxenda, a liraglutide, for example.

My goal is to find what works for the patient, and I can tell you as someone who’s probably prescribed more medications than most people in this country for obesity, is that everyone responds differently to every agent, and sometimes we even must combine agents. The goal is for me to just find what works for that individual, and whatever we need to do that we can do in a safe fashion to work for that individual, to help them achieve a healthy weight and improve their overall health status. That’s the strategy that we’ll entertain.

References:

Hales CM, et al. National Center for Health Statistics Data Brief. Prevalence of Obesity and Severe Obesity Among Adults: United States, 2017–2018. https://www.cdc.gov/nchs/products/databriefs/db360.htm. Accessed June 25, 2021.

Hruby A and Hu FB, Pharamcoeconomics. 2015;doi:10.1007/s40273-014-0243-x.

Orjulea-Grimm M, et al. BMC Fam Pract. 2021;doi:10.1186/s12875-021-01484-y.

Wang Y, et al. Int J Epidemiol. 2020;doi:10.1093/ije/dyz273.