A lifetime of specializing in issues of weight has given psychologist Sarah Adler, PhD, a unique perspective on doctor-patient conversations about weight.
Working with patients at a bariatric clinic made her realize that, in fact, "when you're in a setting where the presenting problem is around weight, it's actually much easier."
The real difficulty comes in, she said, when "primary care doctors are tasked with screening for a whole bunch of issues, but they're not really trained on how to talk to patients about the psychiatric issues of weight."
So what's her advice to primary care physicians who want to have more compassionate and effective conversations about weight?
"I think the first thing that I've learned is that patients don't want their doctors to assume that whatever they're showing up in the doctor's office for has necessarily something to do with their weight," Adler said. "For example, if you're presenting to your primary care doc because you have a sore throat or a virus, and you also happen to have a BMI that's considered to be in an unhealthy range, you might not actually be open to having a discussion about your weight."
Doctors can ask first before discussing weight
Starting by asking if the patient would like to discuss their weight is key, according to Adler. "And if the answer is no, then the answer is no. We have to let the patient lead in terms of their treatment goals and their care goals, and respect them," she said.
Adler also suggests doctors check both their assumptions and biases at the door.
"Weight issues transcend the spectrum, and low weight can be just as big of a problem as high weight," she said. "I've heard many, many examples in the eating disorder world of primary care doctors validating patients with anorexia nervosa or bulimia nervosa, who are on the low end of the weight spectrum, for their healthiness. So making assumptions based on weight is really dangerous, and we have to be really mindful of that."
Cultural sensitivity is critical
Physicians also have to remain culturally sensitive when talking about weight, Adler said.
"I think that in order to provide culturally informed care, it's fairly important to not assume a one-size-fits all model here," she said. "There are different cultures and populations who feel very differently about weight."
Education for physicians is also critical, Adler said.
"I think it sets primary care docs up, again, in a little bit of a tricky position because they're the screeners. They're the ones who are seeing the patient and identifying the potential correlation with high medical risk, and yet we don't equip them," she said. "It's an incredibly complex topic that we, even those of us in the obesity world, don't really have a great handle on. There are biological, psychological and social factors that are at play when we're talking about weight."
In Adler's experience, patients find it especially "invalidating when a primary care doctor talks to them about their weight in a way that doesn't reflect the complexity and the nuance of the issue. It makes them want to shut down."
Adler also raises the question: Should weight loss always be the end goal?
"We're predicated on the idea that weight loss is the thing we're trying to do," she said. "I think that there are a lot of ways that we can talk about how to be healthy without even having a conversation about weight."
This first part of this series featured a primary care physician who shared tips for discussing sensitive topics like weight with patients.
Image by Andrew Rybalko / Shutterstock