Tools to support conversations with your patients about obesity

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Click on the resource above to download a tool to support your conversations with people living with obesity.

For those patients who meet the criteria for obesity or overweight, multicomponent psychological interventions which include behavioural modifications, cognitive therapy, and values-based strategies can be an effective part of weight management. Empathetic and supportive counselling can help patients to address the challenges of weight management.^1,2

Click on the sections below to explore talking points and resources to help shape your discussions with your patients.

Working with your patients: 5A’s of Obesity Counselling³

Key to effective conversations and guiding structured discussions.

Studies have shown that productive conversations between healthcare professionals and patients help people living with obesity to be successful with their weight loss goals.⁴

Studies have also shown that when physicians advised patients living with excess weight or obesity to lose weight, to change their eating habits, or become more active, they were more likely to do so than if not.⁴ While frequent discussions about weight management are helpful with patients, it is the quality of the discussions that actually leads to behavioural changes.⁵

1. ASK

The complex and sensitive nature of obesity can make it difficult to discuss with patients. Taking an empathetic approach, and obtaining the patient’s permission and buy in throughout the conversation can be effective.³ Research has shown that when healthcare professionals employed such an approach, patients were more likely to implement lifestyle modifications for weight loss. It is important to first ask patients for permission to begin the conversation about excess weight.

Different ways to get permission.

Start with a general opening question, such as:³

Tell me more about why you've come here today.

Do you have any other health concerns that you'd like to talk about?

Tie it to symptoms or other problems that the patient stated:

Carrying excess weight can be a cause of some of your health concerns. Do you mind if we talk about how weight management could help with this problem?

Do you think your weight might be contributing to the problem that you're having?

Refer to other clinical measures:^2,6

I notice that your body mass index, or BMI, is high, which means you are carrying excess weight for a person of your height. This can affect your health. Is it okay if we talk about your weight?

If we can review your previous test results for a moment, I think it may be beneficial to discuss how weight management would help to improve some of these results in the future.

Advising on health risks and excess weight.

Prior to initiating screening or assessment for obesity, it is important to ask the patient for permission to discuss their weight. It is recommended that you evaluate the patient’s anthropometric parameters to screen for the health risks associated with excess weight.²

Advise your patient on how even a weight loss of 5% to 10% can improve his or her health by reducing the risk of the comorbidities associated with obesity.⁷

Talking points and questions:

Do you have any questions about what it means to have a high BMI?

"BMI is a measurement that helps determine if a person is carrying excess weight for his or her height.⁶BMI isn't a complete measure of health, so we look at other measures like blood pressure, cholesterol levels, and waist circumference that indicate what should be addressed about your health."²

"Because of your weight, you are also at risk of developing several weight-related complications including diabetes, cardiovascular disease, and certain cancers"^8,9

"Weight loss of as little as 5% of your body weight can help to improve your health by improving blood pressure and lipid levels."^7,10

"Achieving modest weight loss is a process that begins with making a few specific behavioural changes to your eating habits and increasing the amount of physical activity you are doing. We can reassess in 3 to 6 months and discuss other treatment options at that time."^11,12

"I can support you in your efforts to improve your health and lose weight. Is that something you would like?"

After initiating a discussion about weight and the risks of excess weight, explain that the next step could be to take a weight history in order to set goals for individual weight management.

Download

Rethinking Obesity Patient Leaflet

2. ASSESS

An obesity-centred history discussion is intended to complement a full clinical and physical assessment to identify metabolic, mechanical, mental health, or monetary factors, as well as medications, that may be the reasons for weight gain.² A successful weight history discussion can result in:

Assessment of root causes that influence eating and activity behaviours¹³

Understanding of past efforts, challenges and successes with their weight management journey¹³

A basis for individual behavioural goal setting²

Main components and goals of a weight history discussion

The following talking points and questions may be helpful to achieve a successful weight history discussion:

Changes in weight over time

Each patient will have gained weight differently. Understanding how and why their weight has changed can provide insight into their weight gain triggers.¹³

Talking points and questions:¹³

When do you think you first began to gain weight?
Do you feel as if your weight has been an issue in the past? For how long?
Have you always carried excess weight?

Factors in weight changes

This discussion involves eliciting your patient's perceptions of causes as well as connecting any past medical causes to changes in weight.¹³

Talking points and questions:¹³

Why do you think weight is a problem for you?
Can you think of any times in your life when you found that you put on a lot of weight?
What do you think was the reason for putting on weight at that time?
How do you handle stressful situations? Boredom? Sadness? Tiredness?

Descriptions of past weight loss efforts

Discuss and understand your patient's past efforts with weight loss, including specific programs or plans, duration, and results.¹³

Talking points and questions:¹³

Tell me about your efforts with trying to lose weight in the past.
Can you describe the program or type of plan that you followed? How long did you stay engaged?
What aspects of those programs or plans were successful for you?
What didn't work for you? What roadblocks did you encounter?
What has triggered your past weight loss efforts?

Current habits

A discussion about your patient's current eating and activity habits and how they might feel about changing their current habits.¹⁴

Talking points and questions:¹⁴

In general, how often do you feel hungry on a scale of 1 to 10, with 1 being "hardly ever hungry" and 10 being "you are always thinking about food"?
Tell me about your current eating habits?
What kinds of things have you done to change your eating habits?
How do your current habits compare to your past efforts with weight loss?
Tell me about your current physical activity habits.
On a scale of 1 to 10, how ready are you to make changes in your current activity patterns?

Weight history patient material

It may be helpful for patients to chart their own history of weight changes over time. This can help facilitate a discussion of appropriate treatment options for the present and future. People gain weight differently over time. Have your patients chart their history with weight changes and the events that were related to those changes on a piece of paper.

See below for an example

3. ADVISE

Setting individual behavioural goals

A discussion about goal setting is a way to help your patients connect their goals with the behavioural changes they can make for better weight management. Align with your patients on realistic and individualized goals as a first step towards creating sustainable long-term changes in behaviour.^1,3Try setting goals that are connected to your patients’ values and objectives. For example, connect the goal of engaging in more physical activity to activities they can do with their children or family, such as going for a walk once a day.

Discussing behavioural goal setting

It can be helpful to refer to the responses for the talking points and questions above, about how weight may affect your patients’ medical, physical, emotional, and day-to-day well-being, and their lifestyle goals and plans.³

Talk about the big picture

There are several things you can do, such as working with your patients to help them set lifestyle goals. To begin the process, here are some questions to consider asking:

What do you want to strive towards? If you think about the big picture of your life, what do you want it to look like? Health? Travel?
Do you have any general goals for overall well-being or how you want to feel better physically, emotionally and medically?
Do you have a certain amount of weight that you want to lose?
Considering your lifestyle goals, we can work together to take the first steps towards what is realistic for you to manage your weight and health

Behavioural goal setting for weight management.³

Focus on sustainable behavioural changes rather than on specific weight targets. Behavioural goals should be SMART: Specific, Measurable, Achievable, Rewarding, Timely. When you are finished discussing the goals, consider establishing a follow-up plan for future appointments.

Specific

Guide patients to set specific goals for changes to behaviours or habits for healthy eating, or activity levels.

What are some healthy eating habits that you feel you can start doing?
What are some activities or hobbies that you would like to start?
Can you begin one or two of these before our next visit?

Measurable

Ask how they will measure their progress toward achievement or know when they have achieved their goals.

What is the best way for you to track your new habits or progress toward your goal?

Achievable

Discuss how confident they feel about achieving their goal. This is a chance for a reality check to revise the goal if patients don't feel confident that the goal is achievable.

Do you feel confident that this is an achievable goal?
On a scale of 1 to 10, with 1 being “not at all confident” and 10 being “completely confident”, how confident are you that you can achieve this goal?

Rewarding

Ask about how initial goals are rewarding to your patient.

Why is the behavioural goal rewarding or important?

Timely

Place a relatively short time frame on the initial goals and revisit whether they are achievable in that time frame.

When will you begin?

4. AGREE

When discussing treatment for weight management with your patients, incorporating medical nutrition therapy and physical activity should be included along with other options available, such as medication and/or surgery.²Patients who have struggled with excess weight may take some time to adopt new healthy habits. As you approach the topic of healthy eating and physical activity with your patients, focus on achievable steps that patients can take toward sustainable lifestyle changes.

Patients could also keep a food and physical activity journal to help them stay on track with these behavioural changes. They can record things like:

Food and drinks consumed
Hunger levels before and after eating
Time spent being active and what types of activity
Overall feelings about the lifestyle changes they are making

By recording the situations and feelings in which people living with obesity make decisions about food, you and your patients may be able to identify areas for change. Patients can bring their journal to each appointment to discuss general patterns. Healthcare professionals are encouraged to provide positive feedback and celebrate any progress made with the patient’s lifestyle changes.

Treatment Options Overview.

Consider which options might best serve your patients and explore the decision-making process with them. A discussion about clinical weight management should help patients to understand:

Treatment options available
Potential impact on bioclinical markers including A1C, HDL, and blood pressure¹⁰
Realistic management goals and expectations

Physical Activity and Healthy Eating: Some talking points and questions.¹¹

Developing healthy eating habits is a significant part of weight management and can have a positive impact on your overall health. It’s important to make the kinds of changes you can stick to over the long term
To help you accomplish your goals, let’s discuss your daily food intake and some changes you can make to facilitate weight management. You may consider writing down or tracking everything you eat and drink each day in a journal or using technology. What kinds of experiences do you have with tracking and recording?
After 3 to 6 months of behavioural changes, we can also discuss some of the medical options available that can further facilitate weight loss and whether weight loss treatments could be right for you
We are here as a team to help you create the right plan and assist you as you progress toward achieving your goals

To help develop a treatment plan that is successful and sustainable it is important to assess each patient’s readiness to change, intrinsic motivation and value, and their goals. Taking a personalized approach to each patient’s obesity management can have a positive impact on their ability to make long-term changes.² Consider each patient's weight history and current situation to determine a follow-up plan for treatment. Follow-up plans should include:^1,2

Assistance in identifying additional drivers and barriers for weight change

Use of appropriate educational resources

Referrals to appropriate healthcare professionals

Weight management appointments

Scheduling weight management appointments

Patients with obesity or overweight have a lifelong disease that will need frequent and ongoing appointments to monitor progress and make adjustments to treatment as necessary. Evidence indicates monitoring and supporting patients through follow-up appointments—whether they be in-person, over the phone, or patient support programs associated with pharmacotherapy, can have positive effects on weight management.¹⁵

5. ASSIST

Research indicates that patients with excess weight feel stigmatized in many areas of their life, including healthcare settings.^3,16The language you use and your environment are two key components to successful weight management. To promote successful interactions with your patients, it is important to consider the following:^3,17

Keys to successful conversations.

To promote long-term improvements in the health of people living with obesity, healthcare providers should initiate conversations with their patients which focus on their values and goals for treatment.² Research has shown that choice of words plays an important role when discussing weight management.¹⁷Certain words should be avoided and other words can have different implications in a different context:

Preferred terms¹⁸
Weight
Excess weight
BMI

Terms to avoid:¹⁸
Fat or fatness
Obesity
Excess fat
Heaviness
Large size
Unhealthy BMI
Unhealthy body weight

Obesity and obese are both clinical terms intended to describe a patient’s condition but can also sound judgmental or labelling in a different context. Referring to a patient as "obese" is something to avoid.¹⁸

Creating a weight bias-free office.

People living with obesity can experience weight bias and stigma in a variety of settings, one of which being in a doctor’s office. You can help to combat this by ensuring your office is appropriately furnished for people with obesity.^2,3,17

Ensure the bathrooms in your office are comfortable for people living with obesity¹⁹
- Have oversized toilet seats
- Toilet fixtures and sinks should be mounted to the floor versus the wall, but should not interfere with wheelchairs
- Bathrooms should be sized to allow for staff assistance on both sides of the patient at the toilet and shower
Open-arm chairs that can support more than 300 pounds
Wide examination tables preferably bolted to the floor
Large adult and thigh blood pressure cuffs
Weight sensitive reading materials
A private room for weigh-ins

In order to diagnose obesity, you will be required to measure your patient’s waist circumference and/or weigh them. Below are a few tips on how to do this in a respectful manner.¹⁷

Ensure weighing scales are in an area which offers privacy
Ensure your scales have a wide platform and handles for support during weighing
Ensure weighing scales measure greater than 300 pounds
When measuring your patient’s waist:²⁰
- Ask them to stand facing you
- Hand them one end of the measuring tape and ask them to hold it at their belly button
- Request they make one turn so that the tape wraps around their waist
- Grasp both ends of the tape and adjust it to ensure the tape is at the level of the upper hip bones and record their waist circumference

References

Vallis T, et al. Canadian Adult Obesity Clinical Practice Guidelines: Effective Psychological and Behavioural Interventions in Obesity Management. 2020. Available at: https://obesitycanada.ca/guidelines/behavioural. Retrieved September 10, 2020.
Rueda-Clausen CF, et al. Canadian Adult Obesity Clinical Practice Guidelines: Assessment of People Living with Obesity. 2020. Available at: https://obesitycanada.ca/guidelines/assessment. Retrieved September 9, 2020.
Obesity Canada. 5As of Obesity Management. 2011. Available at: https://obesitycanada.ca. Retrieved April 1, 2015.
Rose SA et al. Physician weight loss advice and patient weight loss behavior change: a literature review and meta-analysis of survey data. International Journal of Obesity. 2013;37:118-128.
Pollak KI et al. Empathy goes a long way in weight loss discussions. J Fam Pract. 2007;56:1031-1036.
Kushner RF. Roadmaps for Clinical Practice: Case Studies in Disease Prevention and Health Promotion–Assessment and Management of Adult Obesity: A Primer for Physicians. Booklet 2: Evaluating Your Patients for Overweight or Obesity. American Medical Association. 2003.
Pedersen S, et al. Canadian Adult Obesity Clinical Practice Guidelines: Pharmacotherapy in Obesity Management. 2020. Available at: https://obesitycanada.ca/guidelines/pharmacotherapy. Retrieved August 10, 2020.
Twells LK, et al. Canadian Adult Obesity Clinical Practice Guidelines: Epidemiology of Adult Obesity. 2020. Available at: https://obesitycanada.ca/guidelines/epidemiology/. Retrieved September 3, 2020.
Wharton S, et al. Canadian Adult Obesity Clinical Practice Guidelines: Obesity in Adults: A Clinical Practice Guideline. 2020. Available at: https://www.cmaj.ca/content/192/31/E875. Retrieved September 10, 2020.
Seagle HM, et al. Position of the American dietetic association: weight management. J Am Diet Assoc. 2009;109(2):330-346.
Brown J, et al. Canadian Adult Obesity Clinical Practice Guidelines: Medical Nutrition Therapy in Obesity Management. 2020. Available at: https://obesitycanada.ca/guidelines/nutrition. Retrieved September 10, 2020.
Boulé N, et al. Canadian Adult Obesity Clinical Practice Guidelines: Physical Activity in Obesity Management. 2020. Available at: https://obesitycanada.ca/guidelines/physicalactivity. Retrieved September 10, 2020.
Kushner RF. Clinical assessment and management of adult obesity. Circulation. 2012;126(24):2870-2877.
Kushner RF. Roadmaps for Clinical Practice: Case Studies in Disease Prevention and Health Promotion—Assessment and Management of Adult Obesity: A Primer for Physicians. Booklet 4: Dietary Management. American Medical Association. 2003.
Bischoff SC et al. Multicenter evaluation of an interdisciplinary 52-week weight loss program for obesity with regard to body weight, comorbidities and quality of life—a prospective study. Int J Obes (Lond). 2012;36(4):614-624.
Kirk S, et al. Canadian Adult Obesity Clinical Practice Guidelines: Reducing Weight Bias, Stigma and Discrimination in Obesity Management, Practice and Policy. 2020. Available at: https://obesitycanada.ca/guidelines/weightbias. Retrieved September 9, 2020.
Kushner RF. Roadmaps for Clinical Practice: Case Studies in Disease Prevention and Health Promotion—Assessment and Management of Adult Obesity: A Primer for Physicians. Booklet 9: Setting Up the Office Environment. American Medical Association. 2003.
Wadden TA et al. What’s in a name? Patients’ preferred terms for describing obesity. Obes Res. 2003;11(9):1140-1146.
Wignall D. Design as a Critical Tool in Bariatric Patient Care. Journal of Diabetes Science and Technology. 2008;2(2):263-267.
Centers for Disease Control and Prevention. Assessing Your Weight. 2015. Available at: https://www.cdc.gov/healthyweight/assessing/index.html. Retrieved July 15, 2019.

Tools to support conversations with your patients about obesity

Working with your patients: 5A’s of Obesity Counselling3

Key to effective conversations and guiding structured discussions.

1. ASK

Different ways to get permission.

Advising on health risks and excess weight.

2. ASSESS

Talking points and questions:13

Talking points and questions:13

Talking points and questions:13

Talking points and questions:14

Weight history patient material

3. ADVISE

Setting individual behavioural goals

Discussing behavioural goal setting

Talk about the big picture

Behavioural goal setting for weight management.3

4. AGREE

Treatment Options Overview.

Physical Activity and Healthy Eating: Some talking points and questions.11

5. ASSIST

Keys to successful conversations.

Creating a weight bias-free office.

References

Working with your patients: 5A’s of Obesity Counselling³

Talking points and questions:¹³

Talking points and questions:¹³

Talking points and questions:¹³

Talking points and questions:¹⁴

Behavioural goal setting for weight management.³

Physical Activity and Healthy Eating: Some talking points and questions.¹¹