Activity Transcript

Pamela R. Kushner, MD, FAAFP: Hello, I'm Dr Pamela Kushner, a clinical professor at the University of California Irvine Medical Center in Orange, California. I want to welcome you to this program titled “Top 5 Tips for Managing Obesity in Your Patients.” I'm pleased to be joined today by Dr Dan Bessesen. Dan is an endocrinologist and Professor of Medicine at the University of Colorado School of Medicine. Welcome to our discussion, Dan.

Daniel Bessesen, MD: Thanks, Pam.

Dr Kushner: Over the next 15 minutes or so, Dan and I will share our 5 practical strategies that we have found to be helpful in speaking to our patients about weight, and also show how a point-of-care or decision-making tool such as a patient handout might help facilitate these discussions and improve the management of our patients. Tip number one, Dan, when do you bring up the topic of obesity, and how do you discuss weight with your patients?

Dr Bessesen: Thanks, Pam. It's an important topic, and I think at a minimum all of us should feel comfortable with a rapid, quick way of talking about weight with our patients when they bring it up. Sometimes they don't bring it up, but the evidence suggests that people want a safe, non-judgmental environment to talk about this. They want to feel like we want to tell them that it's really not their fault, they didn't choose to have this problem, that obesity is really a chronic metabolic disease that needs chronic management, just like other metabolic diseases like diabetes or hypertension. And our goal really is to focus on what the patient wants, and to give them useful information.

Dr Kushner: I think that's truly great advice. Thank you for bringing that up.

So, what do the guidelines say? The USPSTF guidelines actually recommend screening for and management of obesity in patients. They recommend screening for obesity with a BMI (body mass index) of greater than 30, and it should be offered, and those patients should be referred to intensive multicomponent behavioral interventions. This is of grade B evidence.

What do they mean by that? Well, intensive multicomponent behavioral interventions for obese adults actually involves behavioral management activities, such as setting a weight loss goal with better diet or nutrition, increasing physical activity would be part of a behavioral management activity, addressing that individual patient's barrier to change, and of course, most importantly in my opinion is self-monitoring and strategizing how to maintain lifestyle changes.

Before we move on, please take a moment to answer the following question that is going to appear on the screen.

Now, Dan, I want to ask you a question. How do you suggest connecting with a patient in a "non-threatening" manner?

Dr Bessesen: When I first started doing this, I thought it was my job to tell people what to do. I was the expert and it was my job to manage their weight for them. I realized is really my job is not to be the boss, but the person is the boss. And so my role is much more that of a coach. And so I really need to keep the focus on the person, and really be of use to them. And to do that, the first thing I think is to, rather than pushing out information, which we tend to do a lot of, is to wherever you can, start by asking a question. You may want to say, "You need to work on your diet, Mrs Jones." But rather than that, set it up with a question, "What's most useful for you today? Are you concerned about your weight? And what can we talk about today that would be helpful to you in that regard?" When you ask a question, then you have to really listen to what they say. Sometimes the answer will surprise you. For example, Mrs Jones may say, "Well diets, I've tried them all, they just don't work for me, but I've heard about these new medications." So when you hear that, then it's useful sometimes to just reflect. And what I mean by that is to just say back to the person what they just said. Say something like, "It sounds like you've tried diets before. You want to lose some weight, and I'm with you on that, but you want to hear more about medicines. It's tough to lose weight, so shall we have a conversation about medications? Would that be useful?" So that's a general way that you can approach the conversation that keeps the focus on the person.

Dr Kushner: I think that's very valuable. You're basically seeing what is useful for the patient and letting them decide what is good for their appointment and where they want to go from there. I also think that having a patient point of care handout tool that you can give them might help them continue that visit after they leave you, so they may feel more empowered and comfortable in discussing it at another visit. Basically, what you're saying, Dan, is shared responsibility, am I right, in decision making?

Dr Bessesen: Yeah, I completely agree with that. And really keeping the focus on their goals as opposed to necessarily feeling like it's your job to make them lose weight. Your job is to help them think about this in a productive way.

I think I've outlined the general approach that I would use for asking a question, listen to the response, reflect back what the person has said, provide some empathy, but then really get down to the brass tacks of what are we going to do.

Dr Kushner: I like the word empathy. I like the word validation.

Before we move on, please take a moment to answer the following question that's going to soon appear in your screen.

I do want to bring up something that is the elephant in the room, so to speak, Dan. There is a weight bias that clinicians have against patients. This study is from 2001, where patients who have a higher BMI are associated with less respect by clinicians. Clinicians rated heavier patients to be less self-disciplined, less compliant, and more annoying. And as a patient's BMI increased, clinicians reported liking their jobs less, having less patience, having less of a desire to help the patient, and seeing those obese patients as a waste of their time. So I guess it's not just society that has this internal bias against patients who are obese.

Dr Kushner: Dan, tip number 2, how do you discuss treatment choices with your patients?

Dr Bessesen: Yeah, the time is short, and how can we do this in an efficient way, and do that really in a patient centered way? I think sometimes a patient support handout could be useful here. What I really do is I start with the 4 options here. I say, "Mrs Jones, you could accept your weight where it is. You could do something with your lifestyle, diet or exercise. You could consider a medication or surgery." The accepting weight where it is, that doesn't do very much, but it's easy to do. Surgery is the most aggressive treatment we have, but it requires more of you, more time, more cost and more risk. What would be helpful to talk about today? So that way if I introduce the topic this way, I don't have to talk about everything. We can let the person tell me or tell you what's most useful for them, and then you can use your time effectively to focus on the topic that's going to be most useful to them.

Dr Kushner: Do you mention effectiveness when you're discussing choices?

Dr Bessesen: I do. You can look at the chart and say, and it seems like that's been happening the last year. Diet and exercise can give 3% to 8% or 9% weight loss, and you can put a number to that using their weight. Medications will give more weight loss, from 5 to 12% more than diet alone. Surgery gives the most weight loss, on the order of 20% to 25% weight loss, but with more risk.

Dr Kushner: Dan, can you give us a guide to select treatment that we can share with our patients?

Dr Bessesen: Yes. And authoritative guidelines have suggested and it makes sense, let's use a more aggressive treatment when the problem of weight is more substantial. Diet and lifestyle things are appropriate pretty much for everyone. Medications are appropriate if the BMI is over 30, or greater than 27 with a weight related comorbidity. And surgery is appropriate to discuss with a BMI over 40 or greater than 35 with a weight related comorbidity. So you can tailor your conversation to the person in front of you.

Dr Kushner: Useful. Tip number 3, we need to discuss lifestyle treatment choices with our patients. And how do we discuss lifestyle treatment choices for the patients? I think that exercise is great for overall health in general, but it's not a great way to lose weight. It's very important to maintain weight, and many diets will help a patient lose weight if they're able to stick to them. So basically when people talk to me about what diet they should be choosing, I say there's no one diet strategy that's going to work for everybody. Whatever you're going to do for you that you think will work best is going to be the best diet for you. And I do tell them that willpower is a myth, but basically you need to choose the diet that is healthy for you, but that is going to work for you.

Do you have something you want to add to that, Dan?

Dr Bessesen: I think having a number of tools that you can suggest your people, concrete steps that they can take to work on their diet, especially. I think, again, here's a place we're having a handout that shares some information so that makes it more efficient. People could use a diabetes prevention type program, DPP. They could use a commercial program that uses a point system or uses a structured diet plan. Some of these are done online, some could be done in person, is another choice. Some of those will cost a little bit more, but again, if the person's committed to losing weight, that's a good choice. Low and very low-calorie diet plans can be used if the person needs to reach a weight target in a relatively short period of time, like if you have somebody who's having surgery or an imaging procedure. So that's a good way to lose more weight in a short period of time. And there's lots of popular diet books and other things that people can use.

Dr Kushner: What about alternative dates fasting?

Dr Bessesen: That's a popular approach. Some of it's not well defined. Is it really every other day, or is it 2 days a week, or is it 3 days in a row once a month? So there's not a lot of consensus. Most people use 3 out of 7 days, with non-caloric beverages during the day. And recent studies show that this works about as well as other conventional diets.

Dr Kushner: And I do think it's important to mention that calorie consumption plays a role also. So many of my patients find that if they limit the actual amount of hours that they're eating, they feel better in terms of being able to control their calorie consumption.

Now, Dan, let's go to tip number 4. How do you discuss anti-obesity medications?

Dr Bessesen: Yeah, it's a big topic. I'll tell you what my just key, when somebody brings this up, these are a couple things that I'll say. I'll tell them that there's 6 medications FDA approved currently to help people lose weight, and they provide more weight loss than lifestyle alone. Say the average weight loss is 5% to 12% or 14%, but it's highly variable. Some people lose less, some people lose more, and that it tends to occur over 3 to 5 months. I say that insurance often doesn't pay for these medications, and so knowing what the cost is [is] important because some of these might be outside your reach. I tell people that medicines only work as long as people take them. This is like a blood pressure medicine, which if you take it for a while and then stop it, the blood pressure comes back up. So if the person is considering medications, they need to be open to continuing them long-term if they're helpful.

Dr Kushner: I think it's a very important point.

Dr Bessesen: Yeah. I think in general, the person can choose to try a medicine for a few months, see what the side effects are, see what the cost is, see what the weight loss is, and then decide whether to use them long term.

Dr Kushner: That makes a lot of sense, Dan. So when you're looking at the patient's handout that we're considering, are there certain points you'd want to highlight in terms of weight loss medications?

Dr Bessesen: Yeah. So again, currently we have 6 medicines. There are some new ones coming along that will change the landscape here. They go from older medicines that are less expensive and less effective to newer medicines that are more effective and have been well tested but are more expensive. I think the key thing is to go through the worksheet or a handout that has the medicines listed and identify the key features. For example, phentermine is the least expensive, but it also may have some side effects. Newer medicines like liraglutide or semaglutide are going to be more effective but more expensive. And then a number of medicines are kind of in that intermediate range, with specific benefits that can be outlined on the handout so you don't necessarily have to go over all that at this visit, but talk about it at the next visit.

Dr Kushner: Over 46% of patients with obesity want to have more information about weight loss medications, but yet only 10% of patients are actually getting this information from their healthcare clinicians. And ultimately less than 2% of patients with obesity wind up getting a weight loss medication. And I think it must have to do with the clinician's concerns about safety and efficacy, but there are a lot of medications that are appropriate for treating this chronic disease. So I urge clinicians to get more information.

But moving on to bariatric surgery, Dan, how are you going to mention this to your patients?

Dr Bessesen: Again, I think it's useful just to have a couple of top line items that you can bring up when the patient wants information. For me, I say that bariatric surgery is the most effective treatment we have for weight. It provides 25% to 30% weight loss on average, although again, quite variable. It can put diabetes into remission even 50% or 60% of the time. And the mortality rate is pretty low, 0.03% to 0.2%, which is similar to the mortality of a laparoscopic cholecystectomy. There are of course complications, especially those long-term nutritional complications.

Dr Kushner: I've shared my lifestyle counseling. Do you want to add something to that please, Dan?

Dr Bessesen: Yeah, if I have limited time the couple of things that are right at the top of my list are, as you said, self-monitoring, getting people to actually monitor their weight. Folks don't want to do this, but it's like blood pressure, you can't treat it unless you know what it is. Monitoring diet in detail, monitoring physical activity and mood, and then setting goals that are realistic and achievable, measurable, not just, "My diet's going to improve," but, "I'm going to drink fewer sugar sweetened beverages." And then really lock that down, so at the next visit the person knows what you're going to ask them, and they have some confidence that they can achieve those goals.

Dr Kushner: I think that's great. Before we finish up, I want to remind clinicians that with weight loss, there's a number of physiological responses that will arise that promote weight regaining. Energy expenditure goes down, appetite increases and metabolism favors fat storage. So we want to remember that this is a chronic disease and try to work against these adaptive responses, because they will persist over time.

That being said, I want to thank Dan for the great discussion, and I want you to provide your key takeaways for this audience.

Dr Bessesen: I think your job is not to make people lose weight. Your job is to help people have a productive conversation around their choices around their weight. And I think it's most useful to target the time you have with the person to the topics that are most meaningful to them. And you should feel confident giving brief synopses or information about those key topics, lifestyle, medications and surgery, and a handout might really help you leverage your time. I think your patients will really appreciate your support in this important area for their health.

Dr Kushner: I agree, and I want to thank you for participating in this activity. Please check out the right side of the program page for helpful tools and resources, including the patient handout that Dan and I discussed with you. You can download and print this for your patients. Please continue on to answer the questions that follow and complete the evaluations. Thanks again.

This transcript has not been copyedited.