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?"[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).[2] Although political correctness has affected social etiquette in many areas of life—from gender identity to sexual, racial, and religious identity—bias against overweight people is a continuing social prejudice, Dr Puhl observes. Research shows that healthcare professionals are not exempt from bias against overweight patients. In one study, almost one quarter of nurses admitted that they were "repulsed" by obese people.[3] In another study, a majority of obesity specialists described people who were obese as "bad, lazy, stupid, and worthless."[3] But is being overweight or obese a character flaw, a disease, a genetic condition, or a metabolic issue? Each of these perspectives has its adherents. A study of contestants on the NBC reality television show "The Biggest Loser," in which obese people attempt to lose as many pounds as possible, shed new light on the issue.[4] One contestant, who weighed 430 pounds in 2009, set a program record—dropping 239 pounds in just 7 months. But in subsequent years, despite herculean attempts to keep the weight off, he regained over 100 pounds. Most contestants who were studied, who collectively lost hundreds of pounds, regained much, if not all, the weight—or ended up weighing even more than when they began—despite their best efforts to stay slim. The reason, the investigators discovered, was not a lack of willpower but a quirk of resting metabolism, the mechanisms of which are still not well understood.[4] The contestants, when obese, were burning the normal number of calories for people of their weight. But after years of dieting, their metabolisms had slowed to the point where their bodies were not burning a sufficient number of calories to maintain their hard-won slimness. As the years went by, their metabolisms slowed even more, causing their weight to climb. It was as if their bodies were dragging them, against their will, back to their original weight. Still, ingrained prejudices are slow to change, even in the wake of scientific evidence that refutes the assumptions on which the prejudices are based. When it comes to negative attitudes about people who are overweight, physicians are no exception. In Medscape's 2016 Lifestyle Report, in which over 15,000 physicians in 25 specialties took part, 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.[depression,[suicide,[alcohol abuse,[drug abuse[49% of family doctors, 43% of internists, and 41% of pediatricians who took part reported being overweight or obese.[gastric bypass surgery], and then they didn't come back," he recalls. "I knew they were probably thinking, 'Wow, he's fat! Is he any good?'" In Medscape's Lifestyle Report, 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.[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
