Session 3: Ask – getting a good conversation started
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WHO training course for nutrition, physical activity and obesity in primary care settings
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Session 3: Ask – getting a good conversation started
- 1. Ask – getting a good conversation started Session 3 Acknowledgements Obesity Canada
- 2. 5 As of Obesity Management framework • Ask for permission to discuss weight. • Assess obesity-related risk and potential “root causes” of weight gain. • Advise on obesity risks, discuss benefits and options. • Agree on realistic weight management expectations and on a SMART plan to achieve behavioural goals. • Assist in addressing drivers and barriers, offer education and resources, refer to provider, and arrange follow-up.
- 3. What we know from international experience: patient perspective • Physicians routinely asked and advised patients to lose weight; they rarely assessed, assisted or arranged. • Information from physicians is seldom helpful. • Physicians lack sensitivity in addressing obesity. • Patients want more support in self-management. • Patients want specific tailored weight management strategies. • Patients want reliable resources.
- 4. Recall: primary care setting • Primary care is an ideal setting for weight management. o Long-term patient care establishes the relationships needed for sensitive and complex issues to be addressed. o The embedded nature of weight issues can be harnessed as an advantage, providing multiple starting points for treatment. o Primary care has the space to work on prevention as a goal. • Provider knowledge is only one aspect of weight management. Interventions should address team issues and the work environment, and build upon existing experiences and skills.
- 5. Ask • Weight is a sensitive issue. • Many patients are embarrassed or fear blame and stigma. • So it is important: – to be non-judgmental – to explore readiness for change – to use motivational interviewing – to create weight-friendly practice.
- 6. Ask (adults/paediatrics) • Do NOT blame, threaten or provoke guilt in your patient. • Do NOT make assumptions about their lifestyles or motivation (your patient may already be on a diet or have already lost weight). • Do acknowledge that weight management is difficult and hard to sustain.
- 7. Ask (pregnancy) • Do acknowledge that weight gain in pregnancy is expected. • Do provide education about the recommended amount of weight gain to optimize health. • Do not make assumptions about a woman’s life, lifestyle or motivation. She may be living as healthy as she can, or she may be ready to take action, or in the action stage of making a change.
- 8. Why are obesity discussions difficult? • Obesity commonly triggers the judgemental view that the individual is responsible for their own misfortune and can thus be blamed for their condition; this results in dismissive and sometimes bullying attitudes. • Many health workers struggle with the balance between personal responsibility ("why don’t they just eat less?") and difficulties of medicalization ("the treatments I can offer are either rationed or ineffective").
- 9. Poppy’s comments – a patient with obesity and co- morbidities • “Just because I’m fat doesn’t mean I’m stupid.” • “I’ve got a good brain and even greater is the size of my feelings.” • “I’ve felt degraded, dismissed, stupid and treated like a freak by some of the so-called ‘caring profession’.” • “These phrases raise my hackles: ‘Do you know you’re overweight?’ ‘You need to consider losing weight.’” • “If I come to see you with earache, please treat my earache and don’t go on about my weight – ask me if I want further help.”
- 10. A doctor’s comments may convey something quite different to the patient ... I think you ought to lose some weight. The doctor thinks I’m fat, despite my diet attempts. Your weight is making your joints worse. My pain is my fault. Do you realize your weight is causing your illness? To rescue my dignity I shall have to become either defensive or aggressive – or simply not come back to this doctor. You can’t have your operation until you lose weight. My actual needs don’t count. They are rationing care for obese people. You just need to eat less. This doctor has no idea what it is like fighting obesity.
- 11. Pitfalls to watch out for • Being judgemental – people appreciate discussing their concerns, they dislike being judged by their appearance. • Jumping to conclusions. • Passing on blame. • Being unkind. • Being sensationalist. • Being dismissive. • Frightening patients – fear is a poor motivator but good at generating denial. • Misinterpreting denial.
- 12. Safe openers: let the patient set the agenda Question GP’s hidden agenda Patient perception How do you feel about your weight? Is this a touchy subject? Open invitation to talk about topic that may be of concern. Do you keep an eye on your weight? / When did you last weigh yourself? Where should I start? Is the patient actively engaged or in denial? I can explain whether this is important to me or not. What has happened to your weight over the last few years? Where is the patient on their weight continuum? I can explain some background to my successes/difficulties.
- 13. Or – simply ask permission … Would it be OK if I ask you about your weight?
- 14. Would it be helpful if we talked about your activity levels? Would today be OK, or would you prefer to have a think about it and come back another time? Would you like to hear some healthy eating suggestions that other patients have found useful? We know that weight can affect health/ arthritis/breathing. Is this something you would like to discuss? Lifestyle can have quite an impact on people diagnosed with cancer. Is this something you would like to find out more about?
- 15. Ask • Use motivational interviewing to move patients along the stages of change. • Ask questions, listen to patients’ comments, and respond in a way that validates their experience and acknowledges that they are in control of their decision to change. • If patients are not ready to address their weight, be prepared to address their concerns and other health issues, and then ask if you can speak with them about their weight again in the future.
- 16. Ask Explore readiness for change. • Determining your patient’s readiness for behaviour change is essential for success. Recognize that different patients will be at different stages of readiness. • Use a patient-centred collaborative approach (genuine collaboration that acknowledges that the patient is central). • Initiating change when patients are not ready can result in frustration and may interfere with future attempts to support healthy change.
- 17. Ask – Prochaska’s stages-of-change model
- 18. Sample questions (adults) • Would it be all right if we discussed your weight? • Are you concerned about your weight? • On a scale of 0 to 10, how important is it for you to lose weight at this time? • On a scale of 0 to 10, how confident are you that you can lose weight at this time?
- 19. Sample questions (paediatrics) • Are you concerned about your (child’s) health? • Are you concerned about your (child’s) weight? • Would it be all right if we discussed your (child’s) weight? Depending on a child’s age and developmental stage, it may be more appropriate to speak with parents alone.
- 20. Sample questions (pregnancy) • Could we discuss your thoughts and feelings regarding weight gain during your pregnancy? • Are you concerned about weight gain during your pregnancy? • Would you be interested in information about weight gain during your pregnancy?
- 21. Ask Create a weight-friendly practice. • Facilities: handicapped accessibility, wide doors, large restrooms, floor-mounted toilets. • Scales: over 160 kg (350 lb) capacity, wheel-on accessible, located in a private area and used with sensitive weighing procedures. • Waiting room: sturdy, armless chairs, appropriate reading material – no glossy fashion magazines. • Exam room: oversized gowns, scales, wide and sturdy exam tables, extra-large blood pressure cuffs, longer needles and tourniquets, long-handled shoe horns.
- 22. Exercise A1 Doctor, patient and optional observer (in groups of 2 or 3) • How might you introduce the patient’s weight into the conversation? • What sentences work well? • What element of a phrase causes upset or risks a defensive response? • Role play (patients) How does it feel to be challenged about a topic that is sensitive or difficult?
- 23. Recap • Recognize the importance of discussing weight and physical activity. • Get off to a good start and avoid upsetting the patient. • Recognize the need to begin with the patient’s perspective and understand a bit of the “back story”. • Do not get too hung up on specific dieting regimes or detailed description of a person’s diet.
- 24. Explore confidence in how to move forward Understanding factual nutritional/physical activity information Understanding eating behaviour – to achieve good nutrition in practice Motivational approaches “What to do” “How to do” Swapping “I Can’t” for “I Will” “I get confused with food labels and knowing what is good for me.” “I know what to do but my family doesn’t like it …” “I’d love to lose weight but nothing I try ever works” What does the patient want help with?
- 25. How confident are you about choosing or preparing healthy foods? You mentioned difficulties with your family accepting healthy options. Would you like more help with this? Are there particular aspects of doing physical activity that you struggle with? You said you feel disheartened because previous weight loss was not maintained. Would this be a good area to explore more?
- 26. Consider the resources you/your patient can access • How much time/capacity do you have? “Quick fix” suggestions have no place in weight management. • Ongoing engagement is more important than short-lived bursts of effort. • Ensure any approaches you recommend are accessible, affordable and culturally acceptable to the patient, as well as evidence-based. • Encourage a family-based life-course approach.
- 27. Learning points • The “back story” will typically highlight both emotional and organizational issues. • Most people will have already tried something and have some nutritional knowledge. • Struggling to lose pregnancy weight is a common factor for many overweight/obese women. • Medical causes of obesity are comparatively rare – hypothyroidism, Cushing’s syndrome, medication, genetic conditions. • Although stopping smoking can trigger weight gain, the health benefits of stopping outweigh the harm.
- 28. After you have asked for permission to talk about weight and assessed readiness to change, you may need to have some critical conversations with patients.
- 29. Having critical conversations • Health professional–patient relationship • Talking about weight • Potential barriers for patients
- 30. Therapeutic relationships: what works • empathy • alliance • goal consensus and collaboration • unconditional positive regard • genuineness • feedback • recognition and repair of alliance ruptures
- 31. Therapeutic relationships: what does not work • confrontation • negative processes • assumptions • rigidity • the ostrich • one approach fits all
- 32. What we can do Be clear about expectations and minimize the risk of misunderstandings. This will: • demonstrate respect for patients • acknowledge patients’ autonomy • increase engagement in treatment.
- 33. Critical conversations: talking about weight Have you heard this? • What is a healthy weight? • How much should I weigh? • My goal? Well, I was 65 kg in Year 10, so that would be nice. • 10% weight loss? That’s it? Maybe to start with, but I want to lose more. • I am doing everything you said, but it isn’t working – I only lost a kilo this week! • I need to lose 45 kg to get my hip fixed. • But that girl on TV lost 73 kg in four months, why can’t I?
- 34. Expectations • Weight loss expectations are high. • Evidence-based outcomes are lower than expectations. • Patients want permanent weight loss when regain is normal. • Effort and outcome are mismatched.
- 35. Where do weight loss expectations come from?
- 36. Where do weight loss expectations come from?
- 37. Where do weight loss expectations come from? Classification BMI (kg/m2) Healthy weight 18.5–24.9 Overweight 25–29.9 Obesity I 30–34.9 Obesity II 35–39.9 Obesity III 40 or more
- 39. EdmontonObesity StagingSystem(EOSS) Stage 0 Stage 1 Stage 2 Stage 3 Stage 4 co-morbidity moderate moderate Obesity Sharma AM, Kushner RF. A proposed clinical staging system for obesity. Int J Obes (Lond). 2009;33(3):289–95.
- 40. EOSS predicts mortalityin NHANES III
- 41. Setting a weight goal • First step is not weight loss o Stop the gain and maintain o Assess: is weight loss indicated? Wanted? • Yes? o Target up to 10% of current weight in 6 months, maintain loss at 1 year • Rate? o Up to 1 kg (2.2 lb) on average per week • Outcomes o Improve health, prevent or delay the onset of obesity-related conditions
- 42. How do you talk to your patients about weight loss expectations? 1. Listen to patients’ expectations. 2. Acknowledge that weight management is difficult and requires long-term strategies. 3. Present evidence on weight outcomes. 4. Discuss phases of weight management. 5. Focus on health outcomes.
- 43. Evidence on weight outcomes Intervention Short-term – 6 months Long-term Commercial programmes 4.6% 3% at year 2 Calorie restriction (- 400 calories per day) 5% 3% at 3 years Diet and exercise 8.5% 4% at 4 years, back to baseline by 5.5 years Low calorie diet 9.7% 5% at 1–2 years Medications + lifestyle 8% 7–11% up to 3 years Behaviour therapy 10% 8% at 18 months VLCD (< 800 Kcal) 16% Rapid weight regain
- 44. Weight expectations and goals % weight loss (n+658 adults) All Women Men BMI 25–25.9 BMI >30 Expectation (realistically) 8.0 ± 6.4 9.1 ± 6.6 6.7 ± 5.8 6.8 ± 4.5 9.2 ± 7.8 Goal (ideally) 16.8 ± 9.5 19.7 ± 8.5 13.7 ± 8.5 12.1 ± 9.7 21.2 ± 10.5 This attempt 8.9 ± 7.2 62% achieved “less than expected” • Predictors for higher expectations/goals: higher BMI, younger age, female. • Higher attrition rates for patients who expect the highest reductions. • Challenging to alter patient perceptions of “realistic” weight loss.
- 45. Weight loss expectations from bariatric surgery • Different procedures have different outcomes. • Realistically, 20–30% weight loss. o 20–30% of patients do not achieve “successful” weight outcomes. o Average regain of 21% of total weight lost. o 10–20% of patients regain a significant portion (2–3 years post surgery).
- 46. Weight loss expectations from lifestyle interventions • 20% are successful in keeping 5% weight off with long-term support (McGuire 1999). • Most regain 30% of weight lost within 1 year and 95% within 5 years (Barte 2010). • 6% weight loss (2 BMI points) at 12 months; weight returned to baseline in 5.5 year (Dansinger 2007).
- 47. Discuss the phases of weight management with your patient • Patients want to focus discussion on weight loss outcomes. • Weight loss is only one phase of weight management. • Develop a strategy and plan for all phases: o prevention of further weight gain o weight loss o weight stability/plateau o weight regain.
- 48. It’s not just about the weight Discuss with the patient what the true goals are (health, quality of life, etc.). • What is important for the patient? • What is the goal? • How will you define/assess success? • What is the plan?
- 49. Summary: critical conversations • Use evidence about weight outcomes to structure the conversation. • New evidence is becoming available constantly. • Recognize individual variation and responses to treatment. • Discuss the phases of weight management and develop strategies for each phase. • Keep focus on health, not numbers on the scale or BMI ranges.
- 50. Summary: critical conversations • Building therapeutic relationships. • Critical conversations: what to do? o patient-centred goals o support self-management o expectation management o focus on quality of life o address barriers o set up supports
- 51. Reflection Please take a moment to consider your own practices in the past. • What worked well in conversations you have had in the past? What did not work well? • When you had a situation where the conversation did not work out, were you able to retrieve the therapeutic relationship? If so, how?
- 52. Future practices Please consider your future practices. o How will you balance active listening and empathy with the time constraints of a busy practice? o Do you have personal examples of utilizing the various styles of motivational interviewing (following, guiding, directing)? If so, please discuss.
Notas del editor
- Speaker notes In this session we will provide an overview of obesity as a chronic disease and outline causes and consequences.
- Speaker notes To implement the five key principles, we have created a five-step programme called the 5 As of Obesity Management. This framework has been modified from existing behaviour change programmes in areas such as smoking cessation. There is extensive evidence behind the 5 As programme from other disease areas such as smoking cessation and pain management. In the field of obesity, Obesity Canada (formerly the Canadian Obesity Network) has been working with researchers to evaluate the effectiveness of this framework for primary care practice. SMART = Specific; Measurable; Achievable; Relevant; Timely.
- Speaker notes It is not only the sensitivities of patients that we need to consider. What about our own beliefs about the value of discussing obesity? Do we feel these discussions are a good use of our time? Or a complete waste of our time? Is the topic of weight something we have been told we must talk about – or do we believe we can help our patients in some way? Is this a useful and relevant topic to mention? For certain, we don’t want to push reluctant staff to talk about a problem they think should be squarely blamed on the patient! We are all encouraged to reflect on our own attitudes to obesity before discussing the topic with our patients.
- Speaker notes Poppy, aged 51, is a patient who initially requested a home visit because of knee pain due to arthritis. She later explained some of the background to her morbid obesity, which stemmed from childhood and was intertwined with a complex set of problems – child abuse, financial hardship, agoraphobia, domestic violence and complex family dynamics. Her self-esteem was extremely low, resulting in a tendency to defensive aggression when she sensed a challenge to her lifestyle. Poppy’s daughter took a similarly aggressive stance in defence of her mother – indeed, the visiting doctor who tried to discuss her mother’s obesity was almost hurled out of the house! But they both responded to an initial listening approach and an offer to explore their difficulties. The end result for Poppy was not any significant change in her BMI but a very different and more positive approach to accessing health care and taking more responsibility for her health. She had counselling, which helped address her underlying low self-esteem to some extent. Her complex problems, however, continue, although her diabetes is now more actively managed and her depression is more stable. She has declined the offer of bariatric surgery.
- Speaker notes Ask how often we, as health professionals, question how our comments and well-meaning advice actually come across. How much do we use a patient’s body language to modify the approach we take? The first column gives a set of comments that are ones to avoid. They demonstrate approaches that are judgemental, blaming, superficial and dismissive. It is no surprise that they might result in upset. The last comment, in particular, is one to avoid. There is nothing simple about obesity – other than gaining weight in the first place. If the solutions were easy, nobody would have a weight problem.
- Speaker notes You may convey any of these impressions without realizing it. What body language changes might indicate that a comment is not being received in the way it was intended? Fear is a poor motivator – it is more likely to induce resistance than change. Make sure you do not misinterpret denial – don’t imagine a patient does not realize they have a weight problem. Denial – dismissing or denying an evident weight problem – commonly stems from a patient being pushed into facing a problem they do not feel equipped to deal with. It is easier to ignore the problem altogether than be seen to fail to solve it. They may have tried and failed – perhaps they have tried hard and failed miserably. Denial means “I don’t want to think about this insoluble problem”, not necessarily “I don’t realize I have this problem.” We “deny” all sorts of things – such as those piles of papers we should have sorted through months ago or that pile of clutter behind the sofa. Denial might mean “not now” rather than “not ever”. But we should be careful about forcing the issue – making someone face a problem that feels insoluble might result in hostility or despair. Consider the sage advice to “choose your battles”. Denial might simply be a sign that the patient is focusing on a different battle right now.
- Speaker notes These questions are designed to “set the scene” and indicate where next to take the conversation. How do you feel about your weight? – This allows you to open the conversation without jumping to any conclusions. It is not uncommon for patients now to reply: “I feel great – I joined a slimming group four months ago and have already lost 5 kg!” Clearly, a very different discussion follows if you get this sort of response, rather than another common reply: “I feel terrible. Every diet I try just fails.” Unless we ask, we will not know if a patient’s weight is currently in a phase of increase, decrease or stability – i.e. where they are on their “weight continuum” (this is discussed more in a later slide). Do you keep an eye on your weight? – This very quickly gives an indicator of engagement. Following up a positive reply with “When did you last weigh yourself?” quickly indicates either active engagement (yesterday, at gym, last week, etc.) or potential denial (“well, not for some months – actually I don’t have any scales”). Remind patients that regular weighing (most days) is one the strongest predictors of weight stability, especially after a phase of active weight reduction. What has happened to your weight over the last few years? – This can be a logical way of helping a patient link their physical symptoms with weight increase (e.g. irregular periods, development of knee pain, etc.). This might help the patient recognize for themselves that controlling their weight may help them manage other aspects of their health. Case example: “So your periods became less frequent and then stopped altogether – which matched a time when your weight had gone up because of a change in your work pattern. We know that increasing weight can make periods disappear for some women. Do you think that weight loss might help your periods to regulate? Has this happened to you in the past?”
- Speaker notes This question was trialled in the Medical School at King’s College Hospital, London, and was found to be a universally acceptable way of opening a discussion about weight. The patient can always decline if now is simply not the right time. At the same time, starting with a polite request acknowledges that this may be a sensitive issue.
- Speaker notes These are all variations on the same theme – putting the topic on the table so that the patient has the option to engage, or come back at a later point. Phrasing the factual information in the third person, rather than the first person, can help avoid implying judgement or blame: “People can find that …” rather than “You might find that …”
- Speaker notes The aim is to try out some of the “safe starter” phrases to see which sentences work well. You could also try out the non-recommended phrases to see what responses they trigger. Role play (patients) How does it feel to be challenged about a topic that is sensitive or difficult? This is a short exercise – no more than 5–7 minutes. After 3 minutes remind groups to swap around and try a different case example. On bringing the group back together, ask for a few suggestions about which sentences were effective. Did asking “how do you feel …” work well?
- Speaker notes People do appreciate talking about things they feel concerned about. They don’t like being judged by their appearance or being forced to face issues they feel they cannot tackle. We can glean very valuable patient information about lifestyle, motivation, barriers and health priorities without getting stuck in a lengthy discussion of dietary specifics. Basically, “why” and “how” are more relevant than “what”. In a short consultation, use this information to guide effective signposting.
- Speaker notes In a short consultation, the primary aim is to support the patient in finding appropriate support – not necessarily to provide all the support yourself. What sort of support is needed? Weigh up the patient’s various comments to help steer them towards support that is relevant to them. Do they need factual information? What is the patient’s understanding of healthy diet and physical activity recommendations? Do they need help to learn (e.g.) cooking skills? Is the family clear about what they should be doing but can’t seem to put the guidance into practice? Perhaps healthy foods are disliked and exercise is unpopular? A behavioural approach may help to understand how behaviours develop in the first place and how they can be influenced. Is motivation the problem? Do excuses and barriers get in the way of good intentions? The next slide suggests simple tester questions to check which direction to take next.
- Speaker notes Your initial conversation may already have shown the direction of travel. Test out your hunch to ensure you are responding to the patient’s needs rather than imposing your own views.
- Speaker notes Wherever possible, convey the need for lifelong commitment to a healthy lifestyle rather than a short-lived blitz. This is particularly important for children, as habits established in childhood are likely to track throughout adulthood. A small change that persists over years will achieve far more than a one-off marathon.
- Speaker notes Allowing the patient to explain their “back story” can give valuable clues about their level of engagement, understanding of nutritional issues, and health priorities. Use this to steer the direction of your conversation. Explore what happened at the point when weight regain began. What factors caused a change in motivation to control eating and/or physical activity? While medical causes of obesity are rare, they should be considered. Investigate if there is clustering of symptoms or a sudden weight change without any apparent explanation. Running some blood tests while reassuring the patient that an abnormality is unlikely can help to show that you are taking the person’s weight concern seriously, but that – after this initial check-up – you would like to move towards exploring weight management options together. Alternatively, you might suggest that if weight control attempts are unsuccessful, then checking blood tests at a later point might be an option. Explain relative benefits if a patient is uncertain whether to try stopping smoking or lose weight – or might be considering both together. More health gain will accrue from stopping smoking first, even if it results in further weight gain. On average, people gain 5 kg (11 lb) in the year after stopping smoking.* * Aubin H-J, Farley A, Lycett D, Lahmek P, Aveyard Paul. Weight gain in smokers after quitting cigarettes: meta-analysis. Brit Med J. 2012;345:e4439.
- Speaker notes For this workshop, we will discuss how we can work together to create a space for critical conversations with patients about obesity and weight. We want to reflect on the conversations we have had with patients. What kind of conversations would you have with a patient you see for the first time? For example, the first thing you may ask is: what brings you here today?
- Speaker notes From the fields of psychotherapy, nursing and health care in general, we know that building a strong therapeutic relationship with a patient is at the heart of any successful communication strategy between patients and health care professionals. Communication is not just about giving information. The goal is to give that information while also helping the patient feel heard, understood and respected. To create that foundation, we need to create an atmosphere of safety and trust so the patient can feel free to tell you what might be working well for them and what may not be working for them. It is very important for patients to be able to trust their health care professionals if they are to sustain long-term behaviour change such as healthy lifestyles or long-term chronic disease management plans for various conditions including obesity. Here are some things that work and don’t work. Some of these things you will be familiar with from other areas of therapy. But this is an opportunity to reflect on some of the things we know from the literature. The idea of empathy is no surprise. Alliance is about the bond you create with your patient – the idea that we are in this together. Having that bond or alliance will support the creation of consensus on shared goals with which we can move forward together. Unconditional positive regard refers to the inherent sense of value we have for the human being we are interacting with. It means we can see their worth and their humanity, but it does not mean that we are going to accept all their behaviours. It is about separating the person from the behaviour. Genuineness (or congruence) – we know that people pick up when there is no sense of genuineness. Feedback is about telling the patient what is working well or what you are noticing in their behavior, and potentially pointing out some incongruencies. For example: “I know that this is what you value but I have noticed that this particular behaviour does not really fit with that value. What do you think about that?” It is about having an open and honest dialogue. Recognition and repair of alliance ruptures: if there is a rupture in the communication or relationship and you can repair it in a way that does not cause the patient to feel that they are being judged, then this will actually help towards building a stronger therapeutic relationship. Sometimes, when there is a rupture in the therapeutic relationship, the patient may stop coming to see us, so there is no opportunity to repair the relationship. But hopefully, if there is already a strong therapeutic relationship, you will be able to see the rupture and to address it.
- Speaker notes A lot of the evidence here comes from the field of addictions. Confrontational approach: one study found that the more the clinician told the client what to do, the less likely the patient was to take their advice. “You have to stop drinking”, “Don’t do that”: these statements were associated with patients increasing their alcohol consumption. Negative processes: this refers to critical and blaming comments. Assumptions: it is important to clarify – where is the patient coming from? What are they thinking? According to the literature, health care professionals are not good at making assumptions about these things, so it is important to ask. Rigidity: you need to have flexibility in your approach – provide options and respect the patient’s autonomy. The ostrich: don’t stick your head in the sand! We often see that something is not working but hang onto the hope that it will change on its own. Generally it will not change on its own, so it is important to address it. One approach fits all: this is about looking at the contextual nature of what we do. Just because one approach works for one client does not mean that it will work for another.
- Speaker notes Be clear about our roles and expectations of what services we can and cannot provide. Patients often come with traditional expectations about receiving some kind of treatment, but it is important to clarify that this lifestyle modification/behaviour change treatment requires active participation.
- Speaker notes Within a primary care environment, patients come in for many reasons – weight might or might not be the reason a patient comes to see you. Once you have identified the issue, you may need to have that critical conversation with them. These are the types of critical conversation that may come up. What do you do? What do you say? How can you prepare for these conversations? We find that we get a lot of these questions. They seem simple enough, but they are not easy to deal with. Healthy? Normal? These are loaded terms and can mean different things. We might tell a patient that the success rate is about 10%. That is a hard conversation. What about when patients come to you and say they need to lose weight for a wedding? Or to get life-saving surgery? Or an MRI? What do you do and say? A lot of patients see things on TV and think that – because you are a health professional – you should be able to help them do as well as, or even better than, the people on TV.
- Speaker notes When you tell a patient that the treatment you can provide is likely to fall below their expectations, it can be really frustrating. There is a real struggle here: the amount of effort and work that your patient will have to do to manage their weight is completely off the chart, and then you have to tell them that – even after all that effort – the treatment will have modest results/outcomes (typically, 10% weight loss). It is also hard for us, as health professionals, to think that all that work we do with patients will only lead to modest outcomes. We want to be rewarded ourselves too. We also have expectations of the programmes we implement. There are operational demands, there are staffing problems, etc. – these are genuine barriers.
- Speaker notes As health professionals, we have to consider where our patients are getting their information from. Which media are they using – magazines, the internet, TV shows like The Biggest Loser, etc.? They see people in the media who have lost half their weight, and then ask why they can’t do that too. They form a distorted image of what is normal. This is a critical conversation to have with patients. Where are they getting these expectations from? Are they getting them from the media? What do they think is “normal”? What are they seeing or reading in the media is a “normal” weight?
- Speaker notes We are all familiar with this table and the idea of height, weight, BMI, etc. But it presents a big challenge: the label “normal” is what people see – and who doesn’t want to be normal? A patient tells you “I want to be a normal weight”, and you tell them that 10% weight loss is the best we can do. Their answer is likely to be: “Well, that only brings me down to BMI 40 and I’ll still be obese. I don’t want to be obese. I want to be normal. I want to be healthy.” This is a critical conversation to have with your patients; and we have to understand that the labels we use in health care – normal weight, healthy weight – also influence patients’ expectations about their weight loss. These labels influence their perceptions of what they want to achieve – they want to be normal, healthy, etc.
- Speaker notes A lot of patients use the BMI classification to determine if they have a healthy weight and to set their weight loss goal. This is in fact incorrect. The BMI range is a disease risk tool. It tells you the lowest risk of mortality (death) based on your height and weight. It tells you that the lowest risk of mortality lies between 18.5 and 24.9; what it does not tell you is that if you lose weight and go from a BMI of 45 to a BMI of 25, you decrease your mortality. The current data on BMI and mortality risk is J-shaped and actually flattening out – there are studies that show that people in the normal and overweight category have lower mortality risk. The critical conversation with your patients is to explain that going down in BMI range does not mean that their mortality rate will necessarily decrease. It just means that where you are in the BMI range today helps to determine your mortality risk.
- Speaker notes Padwal et al. showed that BMI is a poor predictor of mortality and developed a new staging system to classify people with obesity: the Edmonton Obesity Staging System (EOSS).
- Speaker notes Based on EOSS, the risk level varies. People who have a BMI of 30 and are at EOSS stage 0 do not have a greater risk of mortality. It is not how big you are, but how healthy you are. So if you are in a normal BMI range and unhealthy, that increases your mortality risk; but if you have a BMI of 40 and are healthy, your risk for mortality does not change. This is a critical conversation to have with your patient: it is not just about weight and how big you are – it is about how healthy you are. It is critical that you discuss this with your patient and help them understand it. So, when you are setting a goal with your patient, the focus may be stopping the weight gain. You could try explaining this to a patient by saying: if I met you 10 years from now and you were the same weight, would that be a success? Often, they say yes, because they think, “When I was 20, I weighed 90 kg and now I weigh 180 kg, so not gaining weight would have been good.” This can help the patient to understand the value of doing something, even if they don’t see the weight loss they had initially expected. It will take effort and won’t be easy for a patient to stay the same weight over 5 or 10 years, but it will certainly help their health: they need to recognize the value of this goal and put it in their plan. NHANES III = Third National Health and Nutrition Examination Survey.
- Speaker notes This is a good study to show your patients. This systematic review looked at all the various weight loss interventions and assessed their impact on weight. The important thing to look at is the long-term impact of these interventions. What you can see is that all these programmes show weight regain. We all assume – and like to think – that we can lose weight and keep it off, but this is not evidence-based.
- Speaker notes This study looked at over 6000 people and asked them how much weight they thought, realistically, they would lose; and then, how much weight they would like, ideally, to lose. The study found that people’s expectations were that they could realistically lose about 8% of their weight. This is pretty good and could be achieved in an intervention. Some patients’ expectations about what weight loss could realistically be achieved could be reframed. If you then look at answers on ideal weight loss, they are about 16%. This is what the respondents really wanted, but it is not achievable with healthy lifestyles. Younger people and females are found to have higher expectations. This kind of information can help you determine who you need to have this critical conversation with.
- Speaker notes Realistically, someone undergoing bariatric surgery will lose about 20–30% of their excess weight in total. They will not lose 100% of their excess weight and are unlikely to get to a normal BMI. It is therefore important to explain to patients that bariatric surgery – while it has good clinical outcomes – will not enable them to reach their ideal weight or normal BMI range. You can help them to reframe their expectations by providing the relevant evidence. Bariatric surgery is not always successful. Many patients do not achieve successful weight loss outcomes, and many regain weight – most commonly, in year 2 or 3 after surgery. This may be the time that you, as a primary care professional, get to see a patient who has had bariatric surgery, because at this point they will have finished the specialty programme/ intervention.
- Speaker notes Here are the results from lifestyle interventions. Some people are successful, but it is not particularly common. People tend to compare themselves to these exceptional cases. They do not realize that their own experience of not achieving success with lifestyle interventions is in fact common and normal; this is mainly due to the media focusing almost exclusively on the few cases where people do succeed in managing their weight through lifestyle interventions. McGuire MT, Wing RR, Klem ML, Hill JO. Behavioral strategies of individuals who have maintained long-term weight losses. Obes Res. 1999;7(4):334–41. Barte JC, ter Bogt NC, Bogers RP, Teixeira PJ, Blissmer B, Mori TA et al. Maintenance of weight loss after lifestyle interventions for overweight and obesity, a systematic review. Obes Rev. 2010;11(12):899–906. Dansinger ML, Tatsioni A, Wong JB, Chung M, Balk EM. Meta-analysis: the effect of dietary counseling for weight loss. Ann Intern Med. 2007;147(1):41–50.
- Speaker notes Patients want to focus the discussion on weight loss outcomes. Right at the outset, it is important to discuss the different phases of weight management. The first step is to prevent further weight gain. Then we enter the weight loss phase. Next, we need to explain that they will reach the weight loss plateau and may also experience weight regain. The key is to have a plan to deal with each of these phases.
- Speaker notes Weight should not be the measure of success.
- Speaker notes We will discuss the last two points in this slide later.