Obese patients benefit from supportive environment

Scenario: In a climate in which physician performance may be evaluated, in part, on their patients' health outcomes, is it ethical to make a weight-loss program for obese patients a condition of the patient-physician relationship?

Response:

I do not believe it is ethical -- or helpful -- to make weight loss a condition for establishing a patient-physician relationship. Such a policy would violate the first of the American Medical Association's Principles of Medical Ethics, which directs physicians to treat patients with compassion and respect. I also think such a demand would not be helpful in improving my patients' weight or health.

If I were an overweight or obese patient and my new physician told me that I had to lose weight or find another doctor, I would be perplexed and mistrustful: Is this physician trying to sell me a new weight-loss product or service from which he or she will gain financially? Does the physician find working with obese people objectionable? If I am not successful, or regain the weight after an initial loss, will my doctor reject or "fire" me?

Studies have found many obese people come into their physician's office with trepidation; they fear being judged and meeting with the physician's disapproval.

In a 2006 study published in the journal Obesity, more than two-thirds of overweight and obese women reported experiencing bias from their physician or health care provider due to their weight. Obese people commonly report that their weight is a barrier to receiving quality health care. These patients say office environments (e.g., the waiting or exam rooms) are uncomfortable or inaccessible, appropriately sized examination equipment is frequently unavailable, and weighing procedures are humiliating. Patients also report that unsolicited physician advice about weight loss causes them distress.

These common experiences, and fear of them, result in worse health outcomes. For example, obese women have been shown to delay or avoid appropriate preventive care and have a higher rate of canceled visits than do nonoverweight women. Making a patient-physician relationship contingent on a weight-loss effort would serve only to increase the patient's fear of physician disapproval.

I have found that a more cooperative approach to weight loss achieves better results. I start by listening to my patients as they tell me about their efforts to improve their health. Based on their responses, I try to partner with them so they can achieve their goals. I have found it useful to:

Support the patient's goals for his or her health. If these goals include efforts to improve diet, increase physical activity or decrease weight, my interest and advice is more likely to be valued and found useful.

Use patient-centered communication to motivate changes. Research indicates that patients who are allowed to retain control of their activities are more likely to modify their behavior. Asking permission prior to initiating a conversation about weight and related behavior change is a good way to start. If a patient's weight is negatively affecting his or her health, I discuss weight loss in terms of our shared interest in getting at the health problem and ask whether it is OK to talk about weight.

If the patient is not receptive to having such a discussion, my precious time with him or her is best used in a different way.

Eliciting an individual's own ideas for behavior change and then helping him or her develop an action plan based on those ideas is more effective than direct advice-giving or employing techniques that rely on fear and shame.

Acknowledge that weight loss and behavior change are difficult. Our living environment is filled with opportunities to be inactive and enjoy non-nutritious food. When we are not battling the temptations in our communities, we are fighting our DNA. Much of obesity has been found to be genetically determined. The assumption that lack of willpower alone is the cause of an individual's obesity is inaccurate and a gross oversimplification.

Focus on the patient's complaints and concerns rather than on weight. One patient said she went to see her doctor complaining of gastrointestinal pain, but "he didn't even discuss my physical complaints. Instead he kept discussing my weight. He told me how overweight I was many times and insinuated that it was the cause of my complaints. It turns out I had intestinal flu." The lesson: We need to see our patients as more than a number on the scale, and to take their complaints seriously. Overweight people get sick just like people who are not overweight.

Pay attention to the office environment. Simple things like having larger blood pressure cuffs and exam gowns available, making sure scales are situated in a private location, and asking office staff to record the patient's weight without judgment or comment help patients feel more comfortable.

I believe that making our care contingent on a specific weight-loss plan is unethical and counterproductive. We have an obligation to provide a safe and supportive environment for all of our patients, regardless of their weight. If we become partners with our patients, they are more likely to make behavioral changes that result in long-term weight loss and improved health.

A tool kit from Yale University Rudd Center for Food Policy and Obesity outlining strategies to prevent weight bias in care settings is available online (link).

Keith H. Bachman, MD, primary care internist, Kaiser Permanente, Portland, Ore.; clinical lead, Kaiser Permanente's Care Management Institute Weight Management Initiative