How do you tell a patient they need to lose weight?

[Foxxy Cleopatra]

I about posted this in the surgical forum but this is a pretty broad (pardon the pun) topic so I thought I'd try here.

As in many other aspects of medicine, there are many times where it would benefit my surgical patients to lose weight. I am trying to think of a diplomatic way to break it to people- I am a skinny person and don't want to come off as if I am being a b*tch. On the other hand, I see so many people whose weight is a huge (ha) part of their problem and really would benefit from a diet of moderation and excercise.

Usually, I say exactly that, that they need to take things in moderation and try to cut back on the high calorie/ fatty foods. I also tell them that going out in the evening, taking a walk, swim, etc (without going to extremes) is a really good idea.

Any other ideas? I was in a room full of morbidly obese people trying to discuss weight loss today and they looked at me like I was such a meanie! help!

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[DD214_DOC]

I think it would be pretty futile. Most of them probably would just get pissed off and never actually do anything about it.

Then again, what do I know.

 

[ckent]

I guess that it's different when you are a thin woman, because I've never gotten dirty looks when I tell obese people that they are "overweight". Usually they just say that they know that they are already, and they are "trying" to lose weight already, so I just give them more suggestions. A preventative cardiologist that i worked with always told his patients to "halve the pastas, breads, etc that you eat while doubling the vegetables and fruits. Eat fruits for snacks frequently, even before dinner when it will spoil your appetite. Don't drink fruit drinks, drink water or diet sodas, and of course avoid the junk food. Try to lose 1-1.5 lbs per week". It only takes ~2 minutes to explain or write out, and it makes sense. I usually don't tell mildly overweight people that they are overweight, since I imagine that they might get upset at that. I just tell them that they need to lose weight because losing weight has been shown to decrease their high cholesterol/blood pressure/whatever they are taking medicines or being treated for. Usually, people don't like to take medicines, so it gives them a goal of losing weight so that they might eventually be able to decrease the dosage of medicine that they take. If that doesn't work, you can always show them one of those BMI and mortality charts. Point to where their BMI is and show them how they are at 2X the risk of dying in 10 yrs over someone with a normal BMI. Telling people that they are going to die if they keep eating seems to help sometimes.

 

[ependymoma]

Foxxy,

A lot of times, the most direct approach works. As a practicing internist (albeit a new one), I usually tell people flat out that they need to lose some weight. Most people are aware of this already and hearing it from a doctor only reinforces it. A kind approach definitely helps. It also helps if you can delineate the reasons that weight loss can be beneficial. It's probably easier for someone with an ongoing relationship with the patient than it is for you as a surgeon. One approach that I often use is to talk about "the long run". Tell them the long term ramifications of being overweight. It's also important to set realistic goals. Telling a 350 pound patient that they have to lose 200 pounds is probably going to be self defeating at best. Obesity is a long term issue.

Your best bets are to be direct about it. Obviously, you can't say "you're too f***ing fat", but you can say losing weight can help with your overall health, you'll reduce your risk of heart disease and diabetes and help with your chances of wound healing.

This is obviously a very simplistic response, but obesity is a complex problem. (one of my many soapboxes) Just mentioning the problem may actually make a difference. It can also help on inpatients if you get a nutrition consult (if you have good nutritionists) to talk about dietary issues.

If one of twenty listens to you, you're doing a good job.

Take a very direct approach. Sometimes it will work.

Take care.

 

[Apollyon]

Originally posted by ependymoma
Your best bets are to be direct about it. Obviously, you can't say "you're too f***ing fat"

You can't? Employee Health (at Duke) - I'm 6', 190lbs. The EH doc says, "Are you muscular or chubby?". I lift my shirt, he says, "Oh, fat."

Not exactly how I did it, when I was in clinic last year.

 

[Annette]

I guess the tough part is avoiding any sense of condemnation or belittlement. As a skinny person, you are suspect immediately just for being skinny. Society is condeming enough without your doctor doing the same thing. Affirm that you know losing weight is difficult. Make certain that weight loss is not your first, last, and all encompassing message. Try and focus on a healthy diet and excersize, not on weight loss itself.

Yes, many of your patients are like to stuggle with weight control; but, if they sense that you care about them even though they are overweight, they will be more likely to listen to you and comply with what you ask them to do.

 

[womansurg]

Docs counsel people all the time about bad health habits which the doc might not share: tobacco use, alcohol use, risky sexual behaviors, noncompliance with treatment recommendations, eating habits, weight...

Be sincere, frank, and collaborative. For example:
Here are the risks of smoking. Are you interested in quitting? What have you tried in the past? Let's try to think of some ways in which you might be more successful. How can I help? Let me tell you some things which have worked for some other people in your situation...

It's important to respect an individual's autonomy and to be sensitive to how very, very frustrated that s/he may already be with regards to dealing with this issue.

 

[drvlad2004]

With my background in nutrition and exercise science, I find it quite sad that physicians tell patients that they should lose weight. However, they are unable to give directions in how to lose weight. This is where the medical profession fails. I'm surprised that physicians often do not refer their obese/overweight patients to nutritionists, "qualified" personal trainers and exercise physiologists.

As per the question, I would be straightforward and honest about telling your patient to lose weight. Also, I make sure to practice what I preach. Obesity is a deadly epidemic and we, as future physicians, need to be aware of that.

 

[md03]

I've never had any qualms about saying something like "have you tried to lose weight". These people know they are overweight and very rarely have any of them not tried. I acknowlege it's hard and try to encourage effort enough just to loose 10 lbs. I've never had a very extensive conversation, though.

Sort of the same with smoking...theres not a soul in today's society that doesn't know that smoking is bad. So I usually say, You know smoking's bad for you right? They say yeah, I say Have you ever tried to quit. They say yeah, but I started again. I say it's hard. Most people have to try several times to quit before they are successful.

Or if I have a smoker who has been unable to go outside to smoke (eg attached to NGT or CT on suction) for several days, I say now would be a good time to quit since you haven't smoked for several days

No harm in being direct as long as you are polite and say it out of concern for health rather than ridicule.

 

[Mad Scientist]

I used to be worried about talking to people about things like this, but not any more. I've never had anyone have an overtly negative reaction when I brought up their weight. I do try to be sensitive about it -- if someone comes in for something else (hypertension, diabetes, etc.) then we talk about that first, then I say something like, "Now, have you ever tried to lose weight?"

Inevitably they have, and usually are actually eager to talk about it -- about the difficulties and frustrations involved. I try to be empathetic (I guess that it helps that I'm 15-20 pounds overweight myself), and continue to empathize that I *know* how difficult it is, but even a modest weight loss can have significant health benefits. People are usually surprised and interested to hear that. I also congratulate them for any weight loss they have acheived, and try to take away some of the stigma of dieting and exercise. We have a nutritionist in our department who has put together what I think is a very practical and livable diet. I promote that as a diet that is not punitive, but is effective.

Anyway, by doing what I've described, I really haven't had trouble talking to people about their weight.

(Now, asking a full sexual history as described in the textbooks is another matter..."So, can you tell me how you clean your sex toys after each use?")

 

[Rads Resident]

"How do you tell a patient they need to lose weight?"

Say ... "You need to lose weight."

 

[UI2003]

Originally posted by drvlad2004
With my background in nutrition and exercise science, I find it quite sad that physicians tell patients that they should lose weight. However, they are unable to give directions in how to lose weight. This is where the medical profession fails. I'm surprised that physicians often do not refer their obese/overweight patients to nutritionists, "qualified" personal trainers and exercise physiologists.

As per the question, I would be straightforward and honest about telling your patient to lose weight. Also, I make sure to practice what I preach. Obesity is a deadly epidemic and we, as future physicians, need to be aware of that.

Having myself employed two nutritionists and two "qualified" personal trainers, I can tell ya that obesity is a complex complex issue. Sending a patient to a nutritionist is only one piece of the puzzle. Nutritionists can be just as non-helpful as docs if they don't take into consideration: 1) the hectic-lifestyle of a med student/intern, 2) the difficulties in battling a sweet tooth, 3) how to deal with a spouse who says he's supportive but then buys boxes of sweets and stashes them in weird spots throughout the house...and I could go on and on. Like a previous poster said, obesity is a complex health concern that takes a ton of time, effort and money (it costs more to eat a healthy diet - visit your local fruits and veggie section to see what I mean).

Getting to the original question - I tell my patients they need to lose weight by doing basically what has already been stated - increasing the fruits/veggies/multi-grains and decreasing simple sugars/fatty snacks and soda. If I have time, I go through a quick example of what the patient eats on a daily basis and suggest substitutions (Grape Nuts vs. Fruit Loops). Also I mention that they don't have to exercise for 30 minutes straight - they can walk 10 minutes here 20 minutes there etc. 30 minutes of exercise is intimidating to most people so I give them permission to break it up. Then there are things like: taking the stairs instead of the elevator if they're going 1 floor up or down, parking farther away from the door so that they're forced to walk further to get to work (store, etc.), joining the local mall walkers club, garden work (most of my patients tend to be older, but you get the drift). For my arthritic or CHF patients I really push the low impact things - expecially swimming and tai chi - most local YMCA's have classes for very low fees. Hope that helps, Foxxy!

 

[fourthyear]

No one has metntioned the appeal of exercising for stress-release. On my family medicine rotation as a student, I'd say at least 60% of people (women especially) had medical complaints related to/exaccerbated by a stressful lifestyle. It was easy to bring up how much an evening walk with a friend/family member who is also trying to loose weight/releive stress would be very relaxing and make them feel they were taking time to make themselves feel better and be healthier.

The biggest barriers to exercising more are time and lack of support . So you have to address how people are going to deal with their other responsibilities - like convincing a spouse to watch the kids for just half an hour or taking the kids with them on walks in strollers or if older bikes, etc. And everyone has a freind/family member who wants to loose weight too so encourage them to seek these people out or to joing a YMCA where they can meet other people in exercise classes. The social benefits of feeling that other people share your goals and your challenges in getting to them is what will help people make a real lifestyle change.

I focus on exercise more than diet, b/c it seems to be you can make people more excited about adding something potentially enjoyable to their life, rather than forbidding them to eat things they've come to know as satisfying in their lives. Yes, you need both diet and exercise for optimal health, but to hook people in you have to find a way to show them they can actually be happy and healthy at the same time.

 

[Lonestar]

the real question should be "how fat they have to be before i tell them that they are fat?"

My answer: when you can't fit into the CT scanner.

 

[fourthyear]

Yeah, I think they need to make CT scanners bigger these days b/c it seems like way too many patients can't fit!!!

 

[Foxxy Cleopatra]

Thanks for the input!

Being non-judgemental regarding societies issues on body image and weight, I have been trying to think of a way to say, "I'm not judging you, I just want to make you aware that your weight is having a negative impact on your condition."

 

[Heathcliff]

Hey Foxxy!

After residency, if you still feel uncomfortable telling patients to lose weight, you can always move to Honolulu! Check out this list of the top fat and fit cities.

 

[DD214_DOC]

"You're fat, lose weight"

Trying to be "non-judgemental" and "sensitive" is what put America into this epidemic of portly peoples to begin with. If they're not being criticized or judged by SOMEONE (it doesn't have to be you) in some way, then they have no incentive to lose the weight. Beating around the bush won't get you anywhere.

The trick is to channel the resulting depression, anger, resesntment, whatever into a healthy, weight-loss-promoting energy.

Or maybe I don't know what I'm talking about. I just like to play devil's advocate, it opens up some new doors for others

 

[seattledoc]

If I sense that weight is a touchy subject, I often start out asking how much they weighed when the graduated, got married etc. They usually say something considerably less than current weight, then I ask what caused the weight gain, and go from there. It'll often open up the perceived cause to the patient, for example, they'll say they stopped exercising, wife cooks too well, etc... This gives you the nice segway into how to lose weight too. It doesn't always work but people usually don't take offense with this approach. Try it.

 

[Tazmaniac]

I have two approaches for two different types of patients:

The cynical one who's heard it before: Overemphasize the importance and hound them. Fight fire with fire

Dr: "Your arthritis/diabetes/heart disease/GERD/etc. etc. will improve with weight loss, and I think that's where we should start first."
Pt: "Yeah, I know, I'm fat, big deal, etc. etc."
Dr: "It IS a big deal, and that's why I'd like to address it, etc. etc."

The sensitive one: Just mention diet and exercise first.

Dr: "Your arthritis/diabetes/heart disease/GERD/etc. etc. will improve with a better diet and exercise. How much vegetables do you eat per day?"
Pt: "0"

Etc. etc. It doesn't always work, but it's worth a shot.

-Todd MSIV USC

 

[gas-x]

i usually don't try too hard to convince people to lose weight. it's the same with smoking, drug use, excessive alcohol use, etc... it usually falls on deaf ears. i mention it, suggest some ideas, and leave it at that. if you don't know what it takes to lose weight at this point, you're a complete putz. i'm toothpick thin and if you told me i had to gain weight to live longer and healthier, it wouldn't take me much thought to figure out what i have to do to pack on the fat!

i've seen my diabetic patients go downstairs to smoke AFTER having a toe amputated. explain that. i've told him several times about his neuropathy. does he listen? maybe a little bit when he's not downstairs eating ding-dongs and ho-hos. he does have 9 more toes. maybe he'll listen before he has stumps.

none of my COPD patients have quit smoking. None of my overweight patients have shed 10 pounds. I'll just see them next time they arrive at the ER for the same recurrent problem.

 

[smartreader]

You said, in so many words, that your own weight (being skinny) is an issue for you when discussing weight loss with an obese patient. Therefore, I must ask you if you would be more comfortable discussing obesity if you weighed in a little heavier. Would it make it easier upon you if you were obese too? Your current weight should have absolutely nothing to due with your reservations on discussing this subject. The more talk about it, the easier it becomes.

 

[carddr]

this obesity thing kinda took me by surprise when I first started my residency last yr...seemed everyone that came in those revolving doors was fat...one guy who got shot on the street and was in a wheel chair, came in and we couldn't get him in the elevator to the OR. He weighted over 450lbs. we had to use a crane...it wasn't funny than but now I see the humor. Some people are depressed and food is their only comfort...the only thing they have control over, so tread lightly here. Think it's important to try and find out where the problem may lie and make suggestions that are appropiate. Others could care less what they look like the've got more important issues in their lives and some how don't get the connection, overeating just may be causing the health difficulties. Stress plays a major role here.

Personally I like the approach: have you ever tried to lose some weight and go from there.

 

[DD214_DOC]

The problem is people are afraid to tell fat people that they're fat and it's their fault. (most of the time). It's not the fault of aggressive marketing by fast food restaurants or whatever other crap they use as scapegoats. It's their fault.

 

[Dr_sax]

I love these type of discussions. I'm obese, but I amazingly DO agree with JKDMed to an extent. Most obese people are obese because they perpetuate an unhealthy lifestyle- myself included.

That being said, I am a FIRM believer that genetics play a major role in it. When I was 10, I just started getting bigger. I didn't eat anymore or exercise less- I just started getting bigger. It didn't help that I ate a "poor" diet, but I also ate that way before I started to plump up -it's not like I was a 10 yr old eating to dull the pain of existence. I would say 90% of my family is overweight/fighting obesity.

If a person is overweight up to a certain level(I'll say 250-300 lbs to accomodate the various BMIs and such), I would emphasize the need to lower his/her weight for health reasons, but I wouldn't press the issue too much. Ask if obesity runs in the family-you'll probably hear a 'yes.' The best thing you can do is provide info and support- not criticism. You start sounding too critical and I assure you, it won't do any good. Helping to erode a person's self esteem isn't a weight loss promoter.

Anyone bigger obviously needs serious help. There's either a major physical problem or, more than likely, a psychological one. Deal with it accordingly- physical and mental therapy. But I admit, if a pt came in weighing 500 lbs, we'd have one long conversation.

Dr_Sax

 

[carddr]

You gonna tell a 5 yr old they are fat...explain to me why a member of the family doesn't deal with this issue. Presuming they aren't part of the problem. Parents who are addicted to "Fast food" just don't get it yet! But it's coming. (my brother-in-law and sister spend over $100. bucks a week on the stuff, everyone in the family has told him, but he chooses to ignore us, beats cooking he says, and well my sister permits it, now what's going to happen when their 3 kids are teenagers, you got it, eating disorders waiting to happen, and that's not even addressing the issues he is going to have with heart disease,he's all ready 40/50 lbs over weight at 36 yrs old) How do you stop this moving train?Man, I would hate to see this get into the court system, it is absolutely a behavior problem. But some hungry(no pun intended) attorney has all ready filed a court case against "fat" foods.

And don't you always feel sorry for that 60/70 lb overweight person with a walking device because they just had a knee operation with that "I am a victim" look on their face??? Like to run up to them and say "LOOSE THE WEIGHT, EXERCISE YOU IDIOT!!!! Especially senior citizens who have all this time on their hands.

And of course there are those who say my parents are obsese therefor...I say yes you are pre-disposed to be fat but you don't have to be, it's up to you. And yes you have a bigger battle to fight. But it can be done. Learn from your parents, think about how they got to 200/300lbs and stop doing what they do and beat this thing. Join a "fat" group if you must...same as alcoholics.

But honestly, most of time I keep these thoughts to myself and wish I had said them.

 

[Dr_sax]

I can see why you restrain in public.

 

[carddr]

yel. I do restrain in public. Are all your brothers and sisters obsese or just you? When you say you are obsese how much over your idea weight are you?

Your first paragraph is very telling. Do you exercise at all? Assume you have all the time in the world.

 

[Dr_sax]

I completely understand your post(after my initial one). I have the same feelings towards some other people- I think we all do. It was a very "dennis leary-ish" vent . I think the same things about people BIGGER than I am.

Would I be overweight if I had eaten very well throughout my life and played sports/exercised frequently...maybe, maybe not. Definitely not as much. But I didn't. I was a kid and kids are dumb. My parents didn't help with what I ate, but I certainly don't blame their cooking habits for me being big now. I'm a grown up, and aside from my belief in some poor genetics holding me back, I believe that I am how I am because of me and only me.

To answer you specifically:
1) Yes, my one sister is overweight. She too began to gain weight in early adolescence. My mother is big as is most of her side of the family. Obesity is present on my father's side, but not to the extent of my mother's(maybe 90+%mom/ 60% dad).
2) I'm 5'10'' and approx 270ish. Earlier in the year I was over 300 but since February I have been trying to lose and so far I have lost maybe 40-50lbs. Right now because of time constraints, my weight is mainly held in check by a good diet. I'm nowhere near what I want, but I'm trying.

I will be happy to answer any other specific questions you might have.
Dr_Sax

 

[carddr]

psy would say you have taken that first important step...recognizing you have a weight problem and two strikes(both parents) against you ever being a skinny person. That said, congradulations on your weight loss, gotta say that's great. You and I both know, now the hard work begins, taking the rest off and keeping it off.

Addressing # 2. I'm also 5'10", (wish I was taller) I weigh around 170lbs and the only one in my family that is happy with their weight. My sisters have to REALLY work at it. My mother carries the obesity gene and fights this battle everyday, sometimes she wins, most times she doesn't. But she keeps trying. We all tell her we have concerns about her health, so she listens and exercises and says she feels so much better, We even buy persoal training sessions for her, she loves those. And we actually take walks with her when we can. Actually she had my sister's dog for awhile and that helped with her walking. So buy your parents a dog that just has to be walked everyday!! Also she has totally given up red meat, eats lots of fish, turkey and chicken. No diet, just cuts back on the amount she eats.

Even with my 80+ hours at the hospital, I play three sports, scoccer, volleyball(we won the champonship last yr) and believe it or not at my age Baseball(presently we are in second place going into the finals). So while I really don't have any exercise routine the activities I chose to play keep me going, although age and lack of the above have taken their toil and I can feel the difference and I am more prone to injuries. Realize my days are numbered in the sports arena so who knows whats going to happen when I hit the forties!! Age just intensifies the weigh concern, as you well know.

Keep up the good work...

 

[DR]

Interesting discussion. I agree that genetics plays somewhat of a role. It is plain fact that some kids can go outside and play and run around and do all the same activity as their counterparts, and eat very much the same diet, and just be fat...while their friends are not. It's just the wayt it is. However, I think there are other factors, as well. I think that if someone has a weight problem, they can adjust their eating style (I hate the term 'eating habits'...as if we don't really need to eat. It's the style of eating that counts) and maintain a lower weight. Are there some who are going to have to eat a more reduced diet than others to maintain the same weight? Yes. YES. It is so important to tell our patients this, because they fixate on this. They look at friends and coworkers and think, I eat way less than he/she does, and look at him/her...they're not fat like me. Someone needs to tell them that, yes, you need to eat less to look like that. It's not fair, but it is so. Some people are blessed with metabolisms that enable them to be less conscious of what they are eating, and still not gain.
With all that said, I do believe that it is also the person's fault to a degree. Although some may need to diet more than others, the fact is that if they want to do it, they have to do it themselves. They need to change their eating style, and keep it that way. That's it. No compromise. That's why I also believe the term "diet" sucks. It implies that there is some temporary alteration in the eating style, and that you do it until you're ready to go off the diet. Bull****. Patients who need to lose weight need to know that they do not need to go on some eating style change for "a while", until they can go off...NO. They need to permanently change the way they eat, and that's it. It's not "I'm on a diet", it's "this is how I eat". Period. Otherwise, they need to be reminded that they will never keep it off. It's unrealistic to think one can keep weight off by going on "diets". Can't happen. It must be a completely permanent change in eating style. Ever see the look on a patient's face when you tell them how they need to change? They look at you like "Wow, how long do I need to eat this kinda stuff?"...and they need to be told "The answer is: for the rest of your life". And if they say "Oh man, I can't eat this crap forever", than you can tell them they'll be like they are forever. Let's face the fact that when patients are in your office, they KNOW they need to lose weight. We are not going to shock them by telling them this. We don't need to do research on how we go about telling them. Just tell them. "Hey, listen, you've got high blood pressure, and you're father had a heart attack at 59. We need to get your pressure down, and you need to lose weight." Period.

 

[Goofyone]

I worked with a doctor this summer at a primary care clinic, and I quickly noticed his approach.

Towards the end of the visit, he would simply ask "So what have you been doing to try to lose weight?"

Simple, direct, eloquent.

I never saw anyone get remotely offended by this.