I got an email from a reader recently who asked a question I wasn’t entirely sure how to answer, so I decided to punt it to you guys instead. Of course, I might be stretching the meaning of the word “recently” when I refer to an email I received over two months ago. Sorry about that, dear reader! I got busy or lazy or both if that’s even possible. Here’s what she wrote:
A brief personal history: I’m typically in the mid-range of the “overweight” section of the BMI scale, I exercise regularly and eat fairly healthy, just a little too much of everything. But, my question concerns my role as a nurse practitioner in a college health setting. I occasionally see students who are at an unhealthy weight and I’m never quite sure how to approach a discussion. I tend to think most of us know if we need to lose weight, we just don’t always do what we need to do. I realize different people require different approaches, but I’m wondering what, if any, tips your healthcare providers may have given you that really helped in your weight loss quest. Thanks for any insight you can provide.
I replied letting her know I’d throw this one out to the blog, and I also mentioned the Health at Every Size philosophy. I believe it’s important that any discussion about a patient’s weight remain health-centered since that’s what you’re seeing a doctor about, your health, not your appearance. If you want makeover tips you can go to Sephora. It’s also possible for you to be overweight but otherwise have perfect health. For instance, I had my annual physical last month and if they gave out grades for your blood work I would have gotten a big, red A inked at the top of my report. I was told to get a bit more Vitamin D, but that was it.
The only negative impact my weight currently appears to be having on my health is that it’s stressing my knees more than if I were thinner. Of course, my weight also makes me more likely to develop health problems in the future, like type II diabetes which my grandmother got in her 60’s. (She happened to be a nurse, BTW.) So if my doctor were to bring up my weight I’d expect him/her to stick to those two topics – my knees and any future health problems.
But, let’s throw it out to you guys. What tips would you give to healthcare providers about how to have a conversation about a patient’s weight? I know many of you have horror stories about medical practitioners who handled this topic really badly.
I wonder if it is helpful at all to talk about weight. It seems to be so linked to appearance. Some people can have healthy habits and be overweight, and some can eat only chili dogs and pizza and maintain a “healthy” weight.
Therefore, I think it is more valuable for doctors – and our society – to talk about those classic good habits; exercise, nutritious meals, stress reduction, portion control. These same habits may or may not lead to weight loss, but even if they don’t there are still real benefits to doing them.
When we have weight loss as the primary goal, we can “fail” even though we’ve increased activity and improved our diets. That’s ultimately not a helpful mindset.
DO NOT SAY WEIGHT!
Ask – do you exercise? How is your diet? Do you eat whole, healthy foods that will nourish your body? Or do you eat processed crap? Focus on the health numbers… blood pressure is high? “losing weight” is not the answer. Getting exercise and eating better foods is the answer… there may be some weight loss as a side effect…
We have an obsession with “fat” in this country… but it’s not “the fat” that makes people unhealthy… being unhealthy and making bad choices often come with some increased fat. And… sometimes it’s perfectly fine to be fit, healthy AND fat!
If someone had explained this to me when I was a kid, rather than just telling me “you’re fat”… I might have made some much different choices and not have ended up where I am today with borderline disordered eating, exercise obsession, and horrifying fear of the social consequences of even the tiniest bit of fat.
I feel like they don’t listen to me when I talk. I guess I don’t really know what they should say, but I would certainly suggest that they listen. When I have addressed my weight with my healthcare practitioners the response has invariably been to tell me I’d be surprised at how many calories are in a soda and that I should start there. Dude, last time I had a soda was when they brought it to me in the hospital! I don’t drink it, haven’t in years. I eat almost no processed food, white flour or white sugar, or and definitely no artificial anything. I don’t have a lot to lose, but it’s stubborn and I worry about my health. I’d like some helpful advice, by which I mean advice that pertains to me. So, yeah, I’d say listen up.
I’m not any sort of healthcare professional, but I’ve been on the other end of it. Unless there’s been a significant change in weight (which has happened to me in both directions), I think just a standard talk about nutrition and daily activity is what’s necessary. If someone’s overweight, they generally know it. Shoot, the exact number of my weight was a big unknown way-back-when, but I certainly knew I’d put on a few pounds, so the fact that I was overweight certainly hadn’t passed me by.
From what I’ve seen of the science, good nutrition and physical activity are the true arbiters of a person’s health. With weight… it gets sticky. If the patient asks about weight loss or gain, then I’d say the specific topic can be broached.
I have brought it up myself when given the opportunity. If a health professional asks, “What are your concerns about your health,” an overweight patient might volunteer concerns about weight. In that case, this NP seems to be in the perfect place to offer empathy and focus on healthy behavior changes that could help with weight loss but will definitely offer health benefits. The NP could also ask how she could help — maybe the patient wants a referral to a nutritionist or would like to know about free exercise classes available in the community. This NP could have a list of those resources available. After all, a fat patient knows she’s fat, but may need help figuring out what to do about it. IMHO, the focus should be on creating a healthy lifestyle and not just on pounds.
Sarah Fowler says
Agree with all of the above. Weight is not a true indicator of health so any discussion should stick largely to lifestyle and habits (mostly activity level and nutrition) unless it has been an extremely sudden change.
A friend, for example, gained tens of pounds within about 6 weeks without changing her workouts or eating. Doctors told her she was just eating too much, wouldn’t look for other answers, and it turned out she had a severely diseased gallbladder that had to be removed and she was days from death!
Ruby Leigh says
I’ve often been asked during routine doctor’s visits various questions about – if I’m drinking coffee? Do I eat fruits and vegetables? … those are pretty general questions that I think would be appropriate for a NP to ask. Perhaps start there and if the patient volunteers information about poor diet choices… she could advise otherwise. Such as “An unbalanced diet can have negative health impacts” Like others commenting I would stick as closely to health aspects and tread very lightly about weight.
Many overweight people have developed a horror of doctors based on terrible experiences with them. I myself now only go to a doctor if I’m bleeding and can’t make it stop. Any health care practitioner should be aware of this website which documents some of them: http://fathealth.wordpress.com/
Rule number 1: treat the issue the patient comes to you with. Don’t use flu as the occasion for a lecture on healthyeating.
Rule number 2: don’t assume overweight explains everything about the troubles a patient presents with.
Rule number 3: don’t act like fat people don’t know we’re fat and you have to enlighten us as to our fatness. We pretty much notice that. Also, don’t assume that because we’re overweight, we have terrible health habits.
If i had to summarize, I’d say — ask us rather than telling us — and then listen to and believe what we say about our own bodies.
I have been morbidly obese the majority of my life. Most of my doctors have completely avoided the topic besides saying that most likely a portion of my knee issues are related to my weight. Recently I had a psychiatrist that I met for the first time, straight up ask me if I considered gastric bypass. I was completely offended and will not see him again. Although through the discussion he was a very nice man that wanted the best for me. He just did not have any tact. A couple of years ago I had a NP that had asked me about lifestyle stuff and she asked me what plan I had to improve my health and we discussed from there. I also went through a medically supervised weight loss and lost a significant amount of weight, but have since gained it all back. The doctor I saw for it though had horrible bedside manner and was horrible at relating and helping me make the appropriate lifestyle changes.
I know I am overweight and that in the long term it effects my health. Yes I do not want to talk about it. It is an uncomfortable topic, but I do appreciate the doctor that tries to discuss it in appropriate manner because I know deep down that instead of avoiding an awkward conversation they care enough to do it any way.
Overall, though I agree that sticking to habits and lifestyle and moving on from there.
My doctor recently told me I need to lose 20 kg (42 pounds I think?) or at least part of that, but she had good reason. I had just been diagnosed as pre-diabetic which is totally reversable and one of the main triggers for type II diabetes is visceral (belly) fat. It actually releases hormones that interfere with insulin take-up. Regular exercise also affects insulin so we talked about that as well.
So in my case it was a genuine issue that is was appropriate, nay essential, for her to bring up. Not just “eat healthy and exercise” but “lose weight”.
I have seen many reports lately about how waist size is a major indicator of risk of cardiac and diabetes problems. Perhaps that should be part of the workup.
The other part is that research says that only 5 percent of people that lose weight will keep it off, so maybe the focus should be on the prevention of gaining in the first place. I know I sure wish I’d known how hard it would be to lose the inches.
I think this is an extremely sensitive subject. I have read studies that show overweight doctors are less likely to mention weight gains or obesity to their patients. Makes sense to me! “Do as I say, not as I do!”
Obesity was not a great concern to me, as far as my health went, when I was younger. But when I hit 50, things started going downhill fast. That’s what I’d like to tell you youngsters that are overweight. Yes, sure you can get around fine now, no high blood pressure or pre-diabetes YET! IT WILL HAPPEN. Joints wear out under all that weight, the blood pressure goes up, chances for diabetes are increased 100-fold if you are overweight.
It got to the point where I avoided going to the doctor just because I didn’t want to hear all this. It was as if I had no health problems other than my weight. Everything wrong with me was attributable to my obesity. That made me mad, and because I am an over-sensitive person, having the doctor address my obesity made me sad, humiliated and very uncomfortable. I’m not sure what the answer is. I know it is quite a dilemma for healthcare providers, as to how far they should go when addressing obesity issues with a patient.
@servetus – GREAT response! Just what I was trying to say!
Joy Weese Moll (@joyweesemoll) says
The best thing my doctor did was not say a word until I started losing and then praise me out the wahzoo when I did. In a college setting, that may not be practical since you often see patients only once.
I thing rather than dealing with this individually in a college setting, it might be helpful to think more about the community. A fact sheet that delineates the healthiest meals from various venues on campus. A workshop on how to lose the Freshman 15, or not gain it in the first place. A brochure with on campus workout options.
I’m not a health professional but I do teach a college freshman orientation course that has a chapter on health and wellness. I try to focus on overall wellness: physical, emotional, social, spiritual, etc. and I try to avoid the words “weight” or “fat”. I bring healthy snacks in and we talk about making the best choices possible in their lifestyle situations. Some live in the residence halls, some commute, and many of them work when they are not in class. I try to focus on the benefits of eating well and exercise, and not on weight or vanity. I share my weight struggles and talk about the facilities that we have on campus: a terrific gym, pools, walking paths, intramural sports, etc. I think people who are overweight know they are overweight so it’s better to give them some guidance on improving their lifestyle and not preach at them about choices already made.
My endocrinologist tactfully noted I had gained 6 pounds since my last visit…which is odd for me because I never gain weight because of my quest to win my daily battle with Type 1 diabetes. He asked me simply, “How do you feel about your weight?”, after mentioning the +6. That was enough for me to think about it and not feel pressured. Maybe that won’t work for everyone, but I liked that approach.
I agree with most of what is said here but I do miss one important factor: for me there is such a big psychological component and shame connected to my weight that it sabotages most of my attempts to lose weight. A doctor who focusses on healthy lifestyle changes would only tell me stuff I already know. Asking how my weight makes me feel and going from there would help me more. I think it also is an important question for people at any weight because so much unhealthy habits come from the perception that a person’s value is linked to their weight.