The art of communication – how to talk to your patients about their weight?

Dr Lisa Lawless advises that doctors should be clear, effective, kind, and non-judgemental on the subject of weight

The topic of obesity has never been so prominent in the media.  For clinicians in Ireland the availability of GLP-1 agonists and the recent change in legislation regarding access to publicly-funded IVF have prompted debate around the subject. We should see the increased public awareness as an opportunity to engage with our patients and provide help and support. As doctors, we have a duty of care to inform our patients of the complications and risks of being overweight.  Recent advances have contributed to our understanding of weight gain and provided information to educate our patients about the mechanisms driving weight gain and treatments available. The challenge is in communicating this information in a clear, effective, kind, and non-judgemental way.

The most recent statistics in the World Health Organisation (WHO) European region show obesity posing an increasing challenge, with one-in-three school-aged children, one-in-four adolescents, and almost 60 per cent of the adult population now living with overweight or obesity. Ireland has one of the highest rates of obesity in Europe with 26 per cent of the adult population classified as obese ahead of the 16 per cent European average. When you include those who are overweight as well as those who are obese, the figures rise to over 60 per cent of adults and 20 per cent of children in Ireland who are exposed to the complications and risks of being overweight.

For many of us, opening up what may be a difficult conversation during a consultation in a busy clinic is far from appealing. However, the impact of overweight/obesity on a patient’s physical and mental health as well as the significant socioeconomic implications has never been more apparent and the risks of doing nothing far outweigh any discomfort we may feel.

Opening the conversation with parents around their child’s weight can be even more daunting but, when looking at the potential benefits to the child and family, should not be avoided. If introduced early, education around children maintaining normal levels of activity and healthy diets can be normalised, becomes part of normal culture and is more easily discussed as part of the consultation process.

What is obesity?

Obesity is a complex multifactorial disease defined by excessive adiposity (body fat) that presents a risk to health. It has been identified as a serious public health challenge globally and a major determinant of disability and death in the WHO European region.

Obesity is associated with many diseases that affect multiple body systems. Adverse effects of obesity on health include those that result from the mechanical effects of increased body weight such as some musculoskeletal complications, metabolic effects such as type 2 diabetes mellitus cardiovascular risks, and the effects on mental health. Obesity is also considered a cause of at least 13 different types of cancer including cancers of the breast, colorectum, kidney, liver and ovary, multiple myeloma, and meningioma.

For our patients, obesity can result in stigma and marginalisation, loneliness, pain, chronic illness, and reduced opportunities. Patients with weight issues can be judged and outdated views persist around personal responsibility, over-eating, willpower, and laziness. Obesity is a disease and patients need to be treated with respect and offered support.

How to talk to your patient?

Time, confidence, sensitivity, and good communication skills are key to sustaining our doctor-patient relationships. Educating your patient requires knowledge around the topic you are discussing, the ability to listen and understand the patient’s perspective, the effective communication of information to your patient and an agreed plan of action that is acceptable to you and your patient.

When to introduce the topic of body weight

The right time to open the discussion around your patient’s weight during the consultation is paramount. Many of us use a structured model such as the Calgary- Cambridge Model, but in broad terms the consultation consists of at least four or five distinct parts.

1. Initiation and establishing rapport with your patient.

2. Gathering information about the patient’s reasons for attending, including a screening question to establish if there are any other issues to be addressed and an exploration of why or how the presenting issue effects your patient.

3. Once the presenting issue/s is clear we can do a focused examination.

4. Make a diagnosis or list of differentials that we explain to the patient including potential management options.

5. Closure of the consultation with follow up and safety net advice.

When in the consultation we choose to talk about the patient’s weight depends on whether they are seeking help or advice around weight loss or whether they presented with another symptom or issue. In general, unless weight is the main presentation, my preference is to fully address the presenting issue first and seek permission from my patient to include a measurement of body mass index (BMI) as part of the physical examination. Then, once the presenting issue has been dealt with, I return to the BMI. When appropriate, I try to link weight loss advice with the patient’s current symptoms and incorporate this advice into the management plan. Alternatively, if you cannot incorporate the topic of weight loss into the management of the presenting complaint, it can be gently introduced at the end of the consultation with some opportunistic advice around the health benefits of weight loss, how best to start making small changes, and supports available. Remember, weight is a complex issue and becoming significantly overweight occurs over many years. Behaviours will not change overnight and interventions can be viewed in similar terms to the cycle of change we use in the management of addiction. It may take many brief interventions with advice before patients feel ready to make the necessary changes in their lives. It is our job to repeatedly remind our patients of those changes and the benefits that will result should they choose to act.

Introducing the topic of a child’s weight can more difficult, but it does not have to be. The more we normalise the monitoring of children’s weight into healthcare the easier it is to identify changes early and introduce the conversation with a parent should the need arise. In many other countries the monitoring of a child’s growth and weight is more closely monitored as part of normal developmental assessments than here in Ireland. If, as part of the normal physical examination, you routinely plot growth and weight measurements on a centile chart and discuss this with the parent regularly it will become obvious if any significant changes are occurring and these can be highlighted to the parent at an early stage. This gives us the opportunity to introduce advice around the importance of a healthy diet and exercise in a growing child without focusing on body weight and before it becomes a problem.

The WHO defines overweight and obesity as abnormal or excessive fat accumulation that presents a risk to health. A BMI over 25 is considered overweight, and over 30 is obese.

The complex nature of obesity requires that we as doctors take a holistic, integrated approach to identification, early intervention and treatment. Actively managing overweight and obesity will improve health, quality-of-life and overall mortality while reducing healthcare costs. The limitations of BMI should also be acknowledged and local adaptation requires appreciation of body habitus, age, and ethnicity to name a few. The identification of comorbidities and the measurement of waist circumference are also helpful in assessing risk

Lowering the risk of overweight and obesity includes reducing the number of calories consumed from fats and sugars, increasing the portion of daily intake of fruit, vegetables, legumes, wholegrains, and nuts, and engaging in regular physical activity (60 minutes per day for children and 150 minutes per week for adults). In babies, studies have shown that exclusive breastfeeding from birth to six months of age reduces the risk of infants becoming overweight or obese.

Medication for obesity

The following medications are available for the adjunct management of obesity.

• Orlistat (Xenical or Alli).
• Naltrexone/bupropion (Mysimba).
• Liraglutide (Victoza and Saxenda).
• Semaglutide (Ozempic and Wegovy).

As well as diet and exercise, medications can be used as an adjunct to help improve weight loss in obese patients. Orlistat works in the gut to reduce the absorption of fat that is then excreted in faeces. Naltrexone/bupropion works on receptors in the brain to suppress feelings of hunger.

The use of type 2 diabetes medications (GLP-1 agonists, such as semaglutide and liraglutide) for obesity has proved effective and the recent popularity of these medications has resulted in supply issues worldwide. These GLP-1 receptor agonists are given by injection that lowers blood sugar levels and over time can lead to weight loss. 

In general, patients to consider for treatment with a GLP-1 agonist includes those with:

• A BMI of 40 or more.
• A BMI between 35 and 40, and other conditions that could be improved with weight loss.
• A BMI over 30 and a weight-related condition that cannot be managed with medicine.

If evidence continues to demonstrate the benefits of these medications in the management of obesity, we would hope the availability and accessibility for patients will improve.

Of course, all medications come with side-effects and the burden on our patients of having to take or administer daily medications should never be underestimated. Prevention is key, the early identification and education from well informed, caring, and supportive professionals should remain the priority.