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Will Physicians Calling Out Patients On Their Weight Do Anything For Them?



I was recently asked by the editor of the journal Evidence Based Medicine to provide a commentary on an article by Post and colleagues examine the influence of physician acknowledgment of patients’ weight status on patient perceptions of overweight and obesity published in the Archives of Internal Medicine.

The participants (NHANES 2005-2008) were asked whether they had been told by their physician or another health professional that they were overweight. The main outcome measure was the proportion of participants who considered themselves as ‘not overweight’ versus ‘overweight’ in two different BMI classifi cations: overweight (BMI 25.0) and obese (BMI 30.0). Secondary measures included participant perceptions of desired weight and weight loss attempts in the last 12 months.

Outcomes were controlled for age, sex, race, poverty-to-income ratio, marital status, education, whether the patient has a routine source of healthcare and the number of physician visits in the last 12 months.

In participants with BMIs of 25 or greater and 30 or greater,45.2% and 66.4% reported having been told by their physician that they were overweight or obese, respectively.

Participants who reported having been told they were overweight were more likely to identify themselves as overweight (94.0% vs 63.1%) or obese (96.7% vs 81.4%). Similarly, participants who reported having been told they were overweight were more likely to desire to lose weight (96.1% vs 73.7%) and report a weight-loss attempt (64.7% vs 39.0%).

From these finding the researchers concluded:

Among patients who were overweight or obese, patient reports of being told by a physician that they were overweight were associated with more realistic perceptions of the patients’ own weight, desire to lose weight, and recent attempts to lose weight.”

Here are excerpts from the commentary that I had to offer:

Given the cross-sectional and retrospective nature of this study, it may

“be fairer to conclude from this study that patients who recall discussing their excess weight with their physicians are also more likely to consider themselves overweight and obese as well as more likely to recall a recent weight loss attempt.

“….even if identifying and raising the issue of excess weight may motivate more patients to lose weight, it is unclear that this would indeed result in a long-term benefit to patients…..one may argue that simply raising the issue of excess weight and getting patients to try to lose weight on their own may have little effect on long-term health outcomes unless this weight loss is achieved by healthy means and is sustainable in the long term. Evidence suggesting that increased numbers of weight loss attempts are prognostic of future weight gain should also give cause to caution in equating a history of weight loss attempts with better health.”

“…although it is safe to conclude that fewer than half of overweight and fewer than two-thirds of
obese participants have been told by their physicians that they were overweight, it remains unclear whether increasing these numbers to the levels reported in those individuals who have been told will actually result in improved health behaviour and outcomes for the individuals concerned.”

I’d certainly want to hear from my readers on this – has being having your weight pointed out by your doctor ever been helpful? Do my colleagues think that pointing out excess weight to their patients elicits a positive and healthy response? if not, why?

AMS
Edmonton, Alberta

Sharma AM (2011). Physicians’ calling patients on excess weight may provide reality check and increase desire to lose weight in overweight and obese individuals. Evidence-based medicine PMID: 21856640

Post RE, Mainous AG 3rd, Gregorie SH, Knoll ME, Diaz VA, & Saxena SK (2011). The influence of physician acknowledgment of patients’ weight status on patient perceptions of overweight and obesity in the United States. Archives of internal medicine, 171 (4), 316-21 PMID: 21357807

23 Comments

  1. I’ve been either overweight or obese since childhood, and at no time have I NOT been aware of it. One of my guiding principles in everyday life is to not tell people something they already know. A physician telling me I’m ‘obese’ would be doing just that, and would get a ‘no sh*t’ look in return.

    I am (I believe) Stage 0 on the EOSS, and have no patience for physicians who see weight as a ‘problem’ without even asking about my health status otherwise. I’m 43 and weigh within 10 pounds of what I weighed at 22.

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  2. As a child and teen, having this pointed out by my pediatrician was really, really painful, embarrassing, and lead to me not wanting to deal with doctors. I knew that I was heavier than other kids, we had a scale at home that I used way too often, and I dreaded my annual physical for this reason.

    As a young woman in my 20s, I also didn’t need it to be pointed out to me. I had a very painful experience where a nurse refused to prescribe birth control to me because of my size — she certainly didn’t discuss it in a sensitive way at all, she screamed at me that I needed to go to Overeaters Anonymous (this was before Motivational Interviewing was adopted by the HMO I was part of).

    I wonder about gender differences here.

    Why wouldn’t a provider start with a question like “do you have any concerns about your weight, exercise or nutrition?” And let the patient lead from there. If the patient says “no” and then the doctor can say “well, someone who has your BMI might be at higher risk of XYZ, are you interested in knowing more about that?” If someone is comfortable in their body, but they aren’t being physically active, that can be a good opening to talk about being more physically active in lieu of talking about weight directly. If a patient wants help with it, they may be more comfortable bringing it up than the head-on approach.

    Having a regular health care provider is key — someone who can ask you “hey, it looks like you’ve gained weight since I last saw you — why do you think that is?” and listen to the answer, and then ask if someone wants recommendations about how to address it. The idea of having an annual physical seems so old-fashioned, but it really can help catch changes early on and treat them rather than having people uncomfortably gain weight with no help in preventing weight gain.

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  3. re physicians pointing out overweight to patients:
    I am a registered dietitian who has, in the last 10 years, gained about 40 lbs – due to an antidepressant and a resultant downward spiral with my body image and self esteem that has created an emotional eating issue. My life is great now but I still struggle with emotional eating and body image (which has been bad since I was a skinny 8-year old kid). When doctors point out my weight, I feel horrified, embarassed, and like a disgucting failure. Being weighed is an extremely negative experience for me that often leads to weeks of depression and overeating, but I have yet to work with a doctor who respects how psychologically damaging it is for me.
    As an aside, my approach to the weight issues of other people is to have empathy and to come to their defense. I feel that the “normal weight” range is too narrow and leads to psychological issues – that play out in weight and health. But when it comes to myself – I am vicious, mean, hateful, disgusted – and that all comes out after any doctor’s office visit. Frustrating.

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  4. No, it has never been helpful. Usually such comments by physicians have been clumsy and almost insulting. One stands out — when having an electromyelograph, the doctor asked me if I had ever considered losing weight. Has any American woman ever not considered losing weight? To assume I am unaware I am fat is to assume I am either blind or stupid.

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  5. Having my weight discussed by my insurance company influenced me, mainly because I was surprised by how little they wanted me to lose – they said I was 5 lb overweight, while all the charts said I was 55 lbs overweight. It was cheering to find that the people who actually stood to lose money if I got sick thought I was so near an appropriate weight, so I got to work and lost that 5 lbs and another 5 to boot.

    Of course, I did not manage to keep them off for even a year. However, I have not rebounded as much as I feared I would.

    There are plenty of people willing to give advice on how much one needs to lose, and how. But I’ve seen few except fat-acceptance advocates (who obviously have an axe to grind) who give advice on how to be healthy and overweight *without* being on a diet. For instance, what level of overweight is best for postmenopausal women hoping to avoid osteoporosis? What fitness level is realistic for an overweight person to aspire to? Your blog seems to be trending against the ‘lose weight or die’ message, but what is the replacement message going to be?

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  6. Point out the obvious and you still have no workable solution for most of us, so pointing out that we are obese is just offensive or of little help. All but the blind already knew they have a weight problem. The only solution is eat less carbohydrates, move more anyway in some form.

    Providing a method of dealing with hunger, cravings, streets, low impulse control, reward, addiction, and appetite stimulus and all those other things that drive us to food is beyond the medical doctors scope anyway.

    The real “trick” is making our mind think that we are fat enough and are not hungry, crave nothing, and all our appetites are satisfied.

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  7. Doctors usually point out the BMI range I’m in when I go in for a checkup, but they never ask the right questions. They don’t ask about my weight history. They don’t ask about my family history. They very rarely ask about my habits, and if they do, I always get the impression that they don’t believe what I tell them. Usually they give me advice that’s obviously based on incorrect assumptions. I almost always end up annoyed. Doctors have been having “the weight talk” with me for 35 years now.

    I guess that it’s okay to tell people the label that’s associated with their BMI, but it’s not enough to do that and then advise people who are over the “normal” range to lose weight. The health risks associated with higher BMIs (if the patients aren’t already familiar with them) should be discussed without exaggeration, “threats,” or an overemphasis on weight vs. habits. If a patient is already doing things that lower their risks, that should be acknowledged. BMI range shouldn’t be overemphasized. If you’re going to discuss BMI, then why not also discuss family history, age, sex, stress, and other risk factors?

    Also, people usually know what their unhealthy habits are; eating habits, inactivity, or otherwise. Don’t guess or make unwarranted assumptions. Ask them, believe what they tell you, and don’t prioritize weight over more serious problems. People’s unhealthy habits don’t always make them heavier, and some of the ones that don’t are the worst.

    if someone is a regular smoker, a heavy drinker, or a drug user, then that issue is more important than their weight. If someone has serious mental health issues, then that’s more important than their weight. And of course, if someone has serious medical issues that can be addressed independently, then that’s also more important than their weight. Don’t tell a daily pot smoker to lose weight while not even asking about drug use. Don’t tell a depressed person (or even a binge eater) to lose weight while not even asking about mental health issues. Don’t tell someone with a broken leg to lose weight when their bone needs to be set (I hope I’m exaggerating here).

    In short, there’s nothing wrong with discussing weight as a risk factor, but it’s usually not the most important issue at an appointment. Doctors shouldn’t look on appointments with fat patients as opportunities to bully them about their weight. If they’re going to give advice on weight, then they need to know a lot more than the patient’s BMI. However, they should always prioritize real and present health issues.

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  8. As weight is only an indirect indicator of health, and that most people (see above comments) deal with body image and self esteem issues, I think that pointing out weight as a stand alone issue is counter productive in many cases.

    Rather, I would be inclined to ask about the upstream root challenges: food choices, exercise/activity, sleep hygiene, external stressors and the like because these will be the key factors that patients can learn to modify, control and adapt.

    My own N=1 is that I have adopted a whole foods, gluten free, no added sugar diet and subsequently lost all excess weight while not calorie restricting. I learned to shop for food, prepare it and enjoy it in entirely different ways. I haven’t regained weight or had cravings/uncontrolled hunger. My lab values are all optimal. It’s now an ingrained, automatic lifelong way of eating, but it was a difficult transition and the new habits took a few months to become permanent.

    At no time before, during or after doing this did any of my physicians mention it, respond to it, reinforce it or acknowledge it in any way. But as a nurse administrator, educator and clinician, I know not to take offense – nurses and physicians for the most part are not educated about fundamental nutrition, nor are they educated to be knowledgeable health coaches regarding exercise, activity, diet, sleep, stressor management and other health management parameters.

    What I would recommend is having referrals to experts in these areas available and freely offered to all of your patients. I would also have online resources available, such as the Nutrition Data website, the About.com walking website and other science-based, reliable health focused websites which are geared for patient use. (no jargon, clearly written, integrated visuals, incremental stepped coaching and action plans)

    And I would create a patient tool that describes the EOSS and give it to all patients for their baseline health coaching. Letting patients know where they are on that scale is useful for health coaching and planning.

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  9. I’ve been overweight my entire life and, up until recently, morbidly obese. I am a kidney cancer survivor with one kidney and pre-hypertensive. Approximately nine months ago my primary care physician noted that I had crossed the pre-hypertensive line and reminded me that I only had one kidney. He went through and carefully and respectfully detailed all of the health risks I was facing if I continued with my eating patterns and lack of exercise, particulary with regard to my hypertension. While I have always been so very painfully aware of my weight and the effect it is likely to have on my health, I had never had anyone confront me with it in the manner my doctor did. He didn’t preach to me, he talked to me like a very knowledgable friend. He told me that it wasn’t about being slim, it was about being healthy and living my later years as healthy and mobile as possible. (I’m 47) His words flipped a switch in my brain and I have not looked back since. Weight loss is no longer the goal – health is the goal. Since then, I started making small changes that slowly turned into bigger changes. I’ve lost 65 pounds (65 more to go), my blood pressure is going down and I haven’t felt this good in twenty years. Taking care of myself is work and the work will never end, but it has been worth it. Based on my personal experience, my doctor’s respectful, caring tone and information made all the difference.

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  10. In a word, NO, getting called out on my weight didn’t help. Docs don’t have any solutions that work anyway.

    There was one exception: A doctor I was seeing for pain management very gently slipped in the question, almost as an offhand random thought, if I had ever thought about having weight loss surgery. I was stunned, for the only thing I’d ever heard from doctors was about going to Weight Watchers and other such stupidities.

    THAT doctor told me–the only one who EVER said such a thing–that I was beyond the help of any “diet,” and that diets were likely a big part of my problem in becoming super morbidly obese. (He was right. I got put on my first “diet” at age 7 and it was all downhill from there.)

    THAT doctor planted a seed. Several years later I had the duodenal switch and it saved my life. Thank heavens for one educated doctor.

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  11. Here’s a site of collected stories about how not to call out patients on their weight, and the harm that results: http://fathealth.wordpress.com/

    On the other hand, I think all family docs should be asking all their patients about their eating and exercise habits, and recommending to everybody to get moving and eat their veggies.

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  12. I’m obviously obese (since age 6) whereas my husband is mildly overweight (10 to 20 lbs gained after 50). My husband gets the weight lecture regularly because it looks achievable. He was truly surprised that he overweight and determined to exercise more and eat less and please his doctor. He’s maintained his motivation and commitment over 5 years without actually losing any weight. As his family is all genetically thin, he didn’t grow up in a culture of dieting and had no idea how difficult it is to change a set point. The 10 lbs weight loss goal is much easier psychologically for me when the 10 lbs we’re watching on the scale is on my husband’s body.

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  13. Nope.Never has a Doc. approached me reg my weight.I was the one asking for help,crying+eventually pleading for them to do something.Not one Doc,but several.I do not look very over weight-so I was constantly chastised with;eat less,exercise more,cut back on carbs,your metabolism slows down with age,+somethings not working,but I don’t know what.My favorite from a nurse”you need to talk to someone so you can learn to love yourself on the inside,not how you look on the outside”.

    My suggestion is if Doctors are talking to their patients about their weight:

    1)LISTEN!to what we are saying,doing+FEELING!
    2)Suggestion+solutions would be helpful,instead of being dismissive.
    3)Tests or referrals to someone who could help if you can’t or won’t.
    4)Empathy+compassion would be refreshing.

    Some of us are doing all the right things to lose weight+it’s not working. Doctors need more education regarding weight issues,so they do not inflict further damage to an already devastated+injured patient.

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  14. No. Motivation has to come from within and not from external sources. When the external sources are rude, badly informed and/or lacking basic interpersonal skills motivation gets even lower.

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  15. Why do you all think blind people can’t tell if they are overweight? That is silly! Unless people are talking about psychologically blind.

    If doctors bring up weight, they should proceed to do a thorough assessment, including mood, hormonal, autoimmune and medication evaluation to identify underlying issues so that the actual causes of the symptom of overweight can be addressed.

    That ain’t gonna happen anytime soon… It is so much more fun to blame people for their selfish, stupid, uncontrolled voluntary behavior.

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  16. It would be interesting to have a study that correlates doctors talking to patients about their weight and subsequent ill health. I’ve suffered gastric reflux disease all my adult life, probably because of a hiatus hernia. But, no, anytime I tried to talk to a succession of doctors about it, it was always put down to my weight. This is despite a serious family history of digestive tract cancers and Barrett’s oesophagitis.

    I dreaded the conversation, so I began to avoid discussing any digestive tract problems. When I developed a worsening problem last year, I simply avoided going to the doctor and tried very hard to lose weight, once again, hoping to fix the problem myself. By the time I got to the doctor, I had a stage IV lymphoma.

    Well, the lymphoma cured me of weight problems! I’ve gone from being obese to having a BMI of 19.5. But dang it if that gastric reflux problem isn’t still there. The difference is that now the doctor takes my complaints seriously.

    I wonder how many other people flat out avoid the doctor because of one too many weight conversations. As other people above have noted, anyone who’s fat knows about it. And not one doctor ever managed to give me any realistic help in losing weight, since I was already eating very well and exercising.

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  17. Most people who are “overweight” or “obese” (fat) know it and don’t need to be told that they’re fat (they see it every day when they look in the mirror, every time they go to buy clothes, etc). And until there’s a way to safely and permanently make a fat person thin, what good does it do to tell me I’m fat? I know I’m fat, I’ve been fat for more than 35 years, in spite of every diet, diet pill, and a failed WLS. I’ve maintained my current weight, within 20 lbs, for the last 5 years (at least), my numbers are all good, so I’m metabolically healthy. What good does it do for a doctor to tell me I’m fat? It’s not like that fact is going to ever change, nor is it going to be detrimental to my health.
    Ask me how I’m sleeping, how my digestive issues are, am I getting a balanced diet, how’s my depression, how’s my arthritis doing, etc, but leave my weight out of the discussion.

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  18. I’ve been fat since childhood, growing into being morbidly obese. My primary care doctor, who I’ve been with for over twenty years, is great and never harps on my weight. In fact, it wasn’t until I was hospitalized for clots in my lungs that she even suggested weight loss surgery. Contrast that with a doctor in the ER where I was admitted – she looked at me and the first thing she said was “If you don’t lose weight, you’re going to die”. I was admitted to the hospital for another problem a year later and wouldn’t you know it, I got her again as my admitting doctor and she said the same thing to me.

    And no, it didn’t inspire me to lose weight. I had to do that for myself.

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  19. My doctor telling me to lose weight has never been helpful. We fat people know we’re fat – DA?!?!?! What do you think is one of the primary reasons obese people go to see their family physicians? For guidance and help in losing excess weight.

    It would be far more useful if most of these family physicians had any kind of a remote clue about where a person can find credible, evidence-based information and resources that already exist in their communities and healthcare systems that would indeed help them to better manage their weight.

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  20. There’s one important thing that hasn’t been mentioned here. A lot of people with high BMIs don’t look particularly fat. Is there any point in telling them that their BMIs put them into a surprising category?

    Well, because of the headless fatties used in news stories, who tend to have 40+ if not 50+ BMIs, many people don’t realize that pretty much anyone with a large build is considered obese. As doctors, you may consider it your duty to inform them that they are in a range that puts them at greater risk for some health problems.

    However, as rational people who feel healthy and (for example) are aware that they’re built like like Great Uncle Ted, who lived to be 95, you’re probably not going to convince these patients that they will drop dead within five years if they don’t lose 50 pounds. As a fat acceptance advocate, I think that letting people know just how low the threshold is set for obesity will probably make more people question some of the inflated claims and pearl-clutching in the media and maybe even challenge some of the social bias.

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  21. As a fat (“obese”) woman (BMI currently ~37), anytime my weight has been addressed in a medical setting, it’s been nothing more than a vehicle for fat-shaming and has often been incredibly disrespectful, humiliating and painful for me. The last time it happened, a gyno I’d never met before waited until halfway through my pre-pap smear breast exam to start asking me how much I exercised! It was awful. Even doctors who seemed to understand the principles of health at every size have turned around and fat-shamed me at a later date. Make asking about nutrition and exercise routine for all your patients, and don’t talk to fat patients any differently than thin ones! (And for goodness’ sake, make it part of taking a history. Don’t do it when I’m naked!!!)

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  22. Thomas Gleeson says:
    August 29th, 2011 at 9:18 am
    ‘Physician counselling is effective in promoting healthy behavior’. If a physician’s approach to a patient’s ‘overweight or obesity status’ is initiated as a sensitive and compassionate observation or based on pertinent lab and clinical data– then patients will respond accordingly. In reality, many physicians merely ‘call or point out’ their personal perceptions to the patient in a discriminatory and stigmatizing tone. Patients resent physicians who simply ‘call out’ their perspective and disclose their bias with respect to the patient’s ’self-imposed disorder’, but fall deaf and silent when solutions are sought out during the discussion. Physicians historically have contributed more to the problem than to the solution re obesity. How many times have we heard the standard orthopaedic mantra for knee and hip replacements — “Go out from my office and lose 50-100 pounds; push yourself away from the table. These expensive government subsidized rationed hardware parts must be reserved for patients, who we feel will have a positive outcome for 5-10 years. Please see your family doc for your severe pain, dietary needs and a return appointment in 6-12months. Patient’s awareness, acceptance and willingness to participate in any solution demands far more than a mere physician’s ‘calling out’.

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