Dr. Gulati:
Hi there. My name is Dr. Martha Gulati. I'm going to be speaking today about patient-clinician communication about obesity management.
Patient communication is key for obesity management, and there's many things that we need to talk about. We need to know why should we even discuss weight? We need to understand weight stigmata. We need to prepare a welcoming environment for patients to discuss weight. We need to recognize that words matter. And we need to know how to start the conversation with our patients. So let's go through some of these things today.
The stigmata of obesity is something that I think we underappreciate. For patients, often the way that society views them is that obesity represents a failure of their own personal responsibility or a moral failing on their part. And people with obesity are often blamed for their weight. They are thought to be irresponsible. People with obesity often are told that there's something wrong with them, not just the fact that they have a weight issue. And there's thoughts that people who have obesity don't contribute to society. Ultimately, this translates to our entire viewpoint about obesity and people living with obesity. We think, and even in the medical community, that losing weight is simple and that people with obesity, they're either just people who overindulge or they just have no willpower. We often think that they make irresponsible choices. And again, even our society thinks of patients with obesity as unattractive and uninteresting, unreliable, that somehow their health is less valued than other people. And ultimately, we know there's discrimination for people with obesity, including bullying and cruelty. But I'll say that that includes, even within our medical community, that we treat people with obesity differently.
It starts at childhood. If somebody already has obesity as a child, they experience it in their schools, in their sports, and amongst their peers. But it doesn't stop there. In life, in general, people who have obesity ultimately will experience also bias at their work and in their life. We see bias every day in media. We know within our medical community that there's bias. And of course, even our health policy makers tend to have a bias towards obesity. And ultimately, this has affected how effectively we can even treat our patients who suffer from obesity.
The consequences of weight bias and stigmata are manyfold. There's the obesity-related outcomes. Obviously, just having obesity and continuing to gain weight reduces a person's self-efficacy for healthy eating and healthy behaviors, including physical activity and gym avoidance behaviors. If someone's physical health is affected by obesity, we know they have a higher risk of cardiovascular disease and mortality, but ultimately, they have more cardiometabolic disorders at the same time. The mental health of the patient is important as well. Someone with obesity has higher rates of eating disorders and body disturbances. Also, they have greater depression, anxiety, and suicidal ideation, and they often have more psychological stress at their places of work. And there's health system issues as well. Patients that have obesity often avoid care. Often their symptoms aren't even taken as seriously, and it leads to a distrust for the healthcare system in general. This also results in delayed diagnosis for patients with obesity
When we're trying to create an environment that welcomes somebody to discuss their weight and to feel comfortable, we have to think about all aspects. We need to think about our room. Our room has to be comfortable. The furniture needs to fit, needs to fit the person. We need to think about our scales. Our scales in a private place, is it easily accessible? Can somebody of a certain weight actually even step on those scales? Our examination tables need to fit our patients. Our gowns need to fit our patients. And of course, our blood pressure cuffs need to fit our patients.
Our healthcare community also can't just focus on weight. We need to focus on why your patient is there. Ask permission, though, to discuss weight if it's something that needs to be discussed for their overall health
We also need to remember that the words we use matter. We need to avoid judgmental terms and the easiest way to do that is to be talking about measurements. Measures are quantifiable, things like BMI, waist circumference, those are things that you can talk about, but not be blaming the patient. We also need to use terms more like weight or excess weight, rather than using words like heavy fat, overweight, or obese, directly to our patients. It's easier to talk about the excess weight that somebody has gained without using these labels. And it's also important to talk about offering to lower weight, not improve weight, just lowering it.
And remember that the patient is a person. They are not a disease. So when we talk to the patient, we need to say someone has obesity, rather than they are obese or they are that disease. They're more than the disease alone.
For the patient themselves, they need to understand why their weight matters. Why do we care about obesity? Well, we care about it because it increases the risk for cardiovascular disease. Even if they have no cardiovascular risk factors, it's important for the patient to understand that even without other risk factors, obesity increases the risk for heart disease, for cerebrovascular disease, and heart failure, and that way they can better appreciate why we're focusing on the weight.
The great thing about living today is that we actually have effective treatments, and it's more than asking patients to move more and eat less, which has never really been a solution that effectively help patients lose weight. We have so many things. In addition to diet and lifestyle, we have medications now, and those medications are getting more and more powerful by the day. We also have surgical options, and sometimes people will need a combination of these therapies in order to get to their weight goal. But understanding the different treatment availability and the risks and the benefits can help our patients make informed choices.
We also need to talk about what happens if you stop medications, if that's their choice. Because, you know, obesity is a chronic disease, and it is true that many patients are going to need these medications in some format, if they use them lifelong. We know from the STEP extension trial that's shown here, that after the study stopped and when patients went off the medications, many of them regained their weight. They didn't always go back to their baseline weight, but they did regain the weight. And that's why it's also very important to talk about what we're going to do even after they lose the weight. Will these medications need to be used chronically? Can we do patient education about diet and exercise to help them maintain weight? And if there's eating disorders, we can also address them at that time. It's much easier to do, though, when people are actually losing weight than when we're just talking about weight.
For our patients, we need to talk about choosing the right therapy for the person in front of us. And talking about the efficacy of what medications we're going to use, the safety and tolerability of our medications, cost, and patient preference, ultimately are the way that we'll choose the right therapy for the right person.
So for our patients, for efficacy, we need to know what comorbidities are present. What degree of weight loss are we looking for to improve outcomes? We also want to choose the safest drug for a patient or therapy. And so what contraindications are there for that particular patient? Will we use a drug that's going to effectively get them to their goal weight? We need to prepare them for the journey.
Costs are an important issue, and for some patients, they will end up paying out of their pocket. And we need to know, is that appropriate? Is that something they can do? Or is other therapies a better option?
And of course, the patient's preference, what does the patient want to try? What do they want to avoid?
And ultimately, all these things come together for us to make the best plan for our patients. Again, for some patients, anti-obesity medications may not be the right treatment for the patient. For our new GLP1 receptor agonists, again, thinking about risks why you couldn't use the medication, we need to think about medullary thyroid cancers or multiple endocrine neoplasia. You should not be using the medications if they have those particular disorders.
In terms of safety and tolerability, certainly, there are side effects of some of our anti-obesity medications, but you can educate our patients about how to reduce those side effects so that they can tolerate these medications better. Good hydration, high fiber intake, starting to pay attention to their appetite signal so that if they do stop the medications, maybe they're becoming more in tune with what is the right thing to do. And providing them with nutrition education is also key.
Again, cost coverage is important to talk about and determine if it's going to be covered by insurance. That may matter in some countries, but not in other countries. And that's an important consideration, though, in the United States.
And then, of course, like I said, the patient preference. Shared decision-making is key to everything that we do, and the patient should be at the center of all these decisions. We can't make the decisions for them without them entering the conversation. We recently wrote the statement on patient-centered care for cardiovascular disease and for every disease we say the patient’s at the center and all the other issues surround that patient and that we need to take them into account. Well, it’s certainly true for obesity.
So our communication and summary about obesity management are listed here. We need to understand weight stigma and bias. We need to create an environment that is comfortable for patients who live with obesity. We need to always remember that our words matter. We do need to choose the right therapy for the right patient, but of course, that will involve the patient, and we should have patient-centric care in everything we do, including the management of obesity.
Thank you for your time.
