The Pot Calling the Kettle Black? Many patients are overweight. Many doctors are too. But can a doctor who is overweight or obese be authoritative and effective in advising such patients to shed some pounds? Deep Ramachandran, MD, a critical care, pulmonary medicine, and sleep medicine specialist in Burlington, North Carolina, who has struggled with his weight, puts his finger on the problem. "How," he asks, "do we deliver a message that may be seen as hypocritical?"[1] It's a fair question. Can overweight doctors advise overweight patients to "do as I say and not as I do"? Studies offer contradictory conclusions. Doctors are also divided on the issue, as are patients. But experts in obesity contend that the content of the message—and how it is delivered—are more important than the messenger, whether a doctor is overweight, thin, or somewhere in between. Do Overweight Doctors Need a Special Approach? Some physicians feel that doctors who are overweight or obese need to acknowledge that to patients before offering them advice on slimming down. "You have to own your problems and communicate with patients in ways they can understand," Dr Ramachandran says.[1] He often tells patients that he too struggles with weight loss and knows how hard it is. But experts in obesity disagree. "Regardless of a doctor's own body weight, their communication with patients should be the same," says psychologist Rebecca Puhl, PhD, professor in the Department of Human Development and Family Studies at the University of Connecticut. "Doctors need to acknowledge and communicate that body weight is determined by complex factors; work with the patient to set realistic, measurable goals; and focus on supporting patients to engage in healthy behaviors. It's more productive to focus the conversation on healthy behaviors rather than on the number on the scale." "Discuss what weight-related health behaviors the patient is currently engaging in," Dr Puhl advises. "Identify any barriers or challenges that might be interfering with those behaviors. And set concrete behavioral goals with the patient. For example, replace sugar-sweetened beverages with water. Be physically active 30 minutes each day. Increase your portions of fresh vegetables." "The advice really shouldn't be different, or interpreted differently, on the basis of the body size of the doctor," Dr Puhl insists. "That shouldn't be relevant. A doctor's body size is not an indicator of his or her credibility, training, or bedside manner." Psychologist Sara Bleich, PhD, assistant professor at the Johns Hopkins Bloomberg School of Public Health, agrees. "I don't think you need a prelude that says, 'Well, I'm obese like you. And here's what I do.' I think that physicians need to offer practical advice that works, regardless of the patient." Bias Against Overweight Patients Few issues in medicine are more contentious than the obesity epidemic and what to do about it. According to the National Institute of Diabetes and Digestive and Kidney Diseases, two thirds of adults in the United States aged 20 years or older are overweight (body mass index [BMI] 25-29.9 kg/m2) or obese (BMI ≥ 30 kg/m2). 40% admitted that they had biases toward specific types or groups of patients.56% of male doctors and 48% of female doctors said the factor most likely to trigger bias in patients was the patient's weight.14% of emergency physicians; 11% of family doctors, orthopedists, and psychiatrists; and 9% of internists, pediatricians, and ob/gyns said that their biases affected their treatment of patients.49% of family doctors, 43% of internists, and 41% of pediatricians who took part reported being overweight or obese.45% of general surgeons reported being overweight or obese.a high correlation exists between doctors who are overweight or obese and physician burnout.[10] Many doctors can't find enough hours in the day to see patients and spend time with their families, let alone make time to shop for and prepare healthy meals and exercise with any regularity. In fact, trying to squeeze exercise into a chronically overfull schedule can be a catch-22, ultimately leading to weight problems for an overworked physician. "Count calories and exercise" is appealingly simple advice, notes family doctor Robert W. Donnell, MD, a staff physician at Mercy Clinic in Rogers, Arkansas, who has struggled with his weight.[12] But it's not as easy as it sounds. "The Institute of Medicine recommends at least an hour a day of moderately vigorous physical activity, but for busy doctors, the benefits of exercise come at a high price. With only so many hours in the day, something has to give, and often it's sleep. Ironically, recent research has implicated sleep deprivation as a contributor to obesity. Thus, a compulsive schedule of exercise conceivably could produce diminishing returns if sleep deprivation counters the benefits." Doctors who are overweight often internalize the criticisms of their normal-weight colleagues all too well, as an Internet survey of 498 family doctors, internists, and general practitioners demonstrated.[8]Respondents who were overweight or obese, the survey found, discussed weight loss less frequently with obese patients than doctors with a normal BMI (18% vs 30%). In addition, the heftier doctors were significantly less confident in their ability to provide effective counseling about diet (37% vs 53%) or exercise (38% vs 56%). Where Overweight Doctors May Have an Edge Yet the same survey also showed that "obese physicians had greater confidence in prescribing weight-loss medications and were more likely to report success in helping patients lose weight," says Dr Bleich, who led the team of investigators that conducted it. "Given that so many people are obese, all doctors, regardless of their personal weight, should provide their patients with sound advice." Despite what some patient surveys show, overweight doctors may have even more influence than normal-weight doctors in getting overweight patients to change their eating habits, Dr Bleich maintains. Far from viewing them as hypocrites, "heavier patients tend to trust heavier doctors when it comes to diet-related advice," she says. This may be because overweight doctors may show greater empathy than some of their normal-weight colleagues for patients who have weight problems. Lack of physician empathy is a major complaint on patient surveys, regardless of a doctor's weight.[13] Given the anti-fat bias among doctors and nurses, "how good can a patient-physician relationship be if it's burdened by those kinds of emotions and prejudicial assumptions?" wonders Pennie Marchetti, MD, a family doctor in Hudson, Ohio, who has struggled with her weight.[14] Focusing too much on a patient's weight may harm the doctor/patient relationship, and doctors may miss the chance to discuss more serious problems that a patient may have. Female patients who are overweight or obese, in particular, bear the brunt of "fat-shaming" on the part of physicians. One half of the women in one survey said they had cancelled or postponed their next visit with the doctor until they could shed a few pounds.[9] "Perhaps that's why obese women get fewer preventive pelvic exams than their thinner counterparts," Dr Marchetti speculates.[14] "On the other hand," she says, "heavier healthcare professionals are less likely to categorize the obese in negative terms. So it's fair to conclude that, absent the barrier of disdain, they are able to build better relationships with obese patients."[14] "There's no evidence that obese patients are any more compliant with recommendations given by fat doctors," Dr Marchetti hastens to add, "but they may read less implicit condemnation in that advice than they do when it comes from a thinner doctor. Empathy is a very important tool in the doctor's bag, and there's no doubt that a doctor who understands firsthand how difficult it is for some of us to maintain an ideal body weight has more empathy with his or her patient's struggles."[14] The 'White Coat Effect' Regardless of whether or not doctors are overweight, many do not broach the subject of healthy lifestyle changes with their overweight or obese patients, for a variety of reasons, Dr Bleich notes. Doctors may not know what advice to give, she points out. Nutritional counseling, for example, isn't commonly taught in medical school. Or doctors may not want to embarrass a patient by bringing up her weight. Or they may be concerned that a discussion about lifestyle changes will take too long for a 10- or 15-minute visit. Or they may believe that such discussions are a waste of time. After all, lifestyle regimens are a lot harder to adhere to than medication regimens, which many patients also fail to follow. But don't discount the power of a doctor's authority—what Dr Bleich terms the "white coat effect." "Just hearing what you should do from the doctor, regardless of the doctor's weight, has a motivating effect on the patient," she asserts. This was confirmed in study by investigators at the University of Georgia.[15,16] It found that patients were motivated to lose weight after their doctors advised them to do so—even when the patients weren't prepared to hear the message. A doctor's recommendation was associated with a 10-lb weight loss among women and a 12-lb weight loss among men. Although the study didn't show that this advice definitely produced the desired result, it was linked to greater odds of weight loss. One reason a doctor's recommendation may lead to greater weight loss is that a doctor is able to assess multiple factors—such as diet, exercise and medical history—to determine whether a patient is at risk for obesity, says Joshua Berning, PhD, the study's lead author.[16] "Oftentimes, we have a sense of complacency with our own health," Dr Berning says. "A good physician can help us understand what kind of health trajectory we are on and how we can improve it." But, he adds, "the problem is that doctors often don't take time to talk with their patients about weight." Talking to Patients About Their Weight Scott Kahan, MD, MPH, medical director of the Strategies to Overcome and Prevent (STOP) Obesity Alliance at George Washington University, recommends that doctors use a technique called "motivational interviewing," a method for talking with patients that encourages them to reveal their barriers to adherence and helping them address those barriers.[17] Although learning the basics can take several hours of training (seminars and workshops are available online) and becoming an adroit motivational interviewer requires practice, the technique can yield positive results in as little as 5 minutes, says behavioral psychologist Kim Lavoie, PhD, co-director of the Montreal Behavioral Medicine Centre in Montreal, Canada, who has trained thousands of doctors and other providers in the method.[18] Simply asking a patient for permission to discuss her weight can have a positive effect, she says, by giving the patient greater emotional investment in the discussion. "Doctors often say that there is so much to cover in a visit that they don't have time to talk about weight," Dr Kahan observes,[17] "but they can at least start a conversation.You don't have to do it all at once. This isn't something that you solve in a single visit. This is a chronic disease, like diabetes. You can make progress with each discussion." Source
