Starting a Dialogue about Obesity in Primary Care: Respect is Key

Patient Care^® Online recently spoke with medical weight management specialist Sandra Christensen, MSN, ARNP, about her upcoming presentation at the Obesity Medicine Association Virtual Spring Summit that begins Friday, April 23, 2021.

In the video below, Ms. Christensen discusses the unique challenges primary care physicians (PCPs) face when treating patients with obesity, how PCPs can initiate and navigate the complex conversation about obesity with their patients, and why a productive partnership between PCPs and their patients with obesity starts with respect.

Sandra Christensen, MSN, ARNP, is a medical weight management specialist and owner of Integrative Medical Weight Management in Seattle, Washington. Ms. Christensen is also a fellow of the Obesity Medicine Association, where she serves on the Board of Trustees, and is a contributing author to the OMA Obesity Algorithm. Ms. Christensen is also the author of, A Clinician's Guide to Discussing Obesity with Patients.

The following has been edited for clarity.

Patient Care Online: I’m Sydney Jennings, associate editor of Patient Care^® Online. Today I have the distinct pleasure of speaking with Sandra Christensen in advance of the opening of the Obesity Medicine Association’s Virtual Spring Summit held on April 21st where she will be a featured presenter. Ms. Christensen is a medical weight management specialist and owner of Integrative Medical Weight Management in Seattle, Washington, where she provides personalized, comprehensive obesity treatment. Ms. Christensen is a fellow of the Obesity Medicine Association, where she serves on the Board of Trustees, and is a contributing author to the OMA Obesity Algorithm. Welcome, Ms. Christensen.

Sandra Christensen, MSN, ARNP: Thank you, Sydney. It's great to be with you today and I'm super excited to talk about this topic with you and with your primary care audience.

PCO: Yes, me too. According to the CDC, obesity is associated with the leading causes of death in the United States and the latest data show that rates are only increasing. Although my audience of primary care physicians encounters this growing patient population on a daily basis, the reality of supporting weight loss, as you know, is complex. It can be difficult for primary care physicians to know where to begin with diagnosis and treatment for their patients with obesity. Can you speak to some of the challenges primary care physicians face when treating patients with obesity?

Christensen: Well, I think there's a long list of challenges that they face. Obesity is the most common chronic condition in the United States for adults and 42.4% of US adults have obesity and another 33% have pre-obesity, which is a BMI between 25 and 30. So, if you think about it, over 75% of US adults are an unhealthy weight. The primary entry point for most people is primary care, and that is overwhelming just right there. So just the sheer number of patients that they have to assess and funnel into treatment. And then we don't have a system that's set up for primary care to really address it.

People that want to treat obesity a little more seriously in primary care have to set up a separate day, a week, to address it because they just don't have time in their schedules. They have short appointments, and that I think makes it really difficult. And then we don't educate clinicians in their preparatory programs. Not in med school, not in nurse practitioner school, physician assistant school, even though that's changing some, we're making efforts, they didn't get any education on it. So here they are faced with all these patients that have this very serious chronic condition and no education on how to do it. Very little continuing education, although that's improving.

Reimbursement is a challenge as well, and knowledge of how to code an appointment, whether or not insurance will cover it. So I just think there's numerous challenges for people. Also, people with obesity tend to have complications that are pretty serious. And so their time is spent focusing on those, rather than being able to address the root issue. I have a lot of compassion for the challenges that primary care clinicians have for sure.

PCO: These challenges are the basis of your upcoming presentation at the OMA spring summit, "A Real World Approach to Treating Obesity in Primary Care." Could you briefly explain the aim of this presentation?

Christensen: Well, what I really want to do is help primary care clinicians see the value of addressing it, despite all those barriers, to see how addressing obesity will really improve the health of their patients, and ultimately make their lives easier as well, right? Like, if they spend all their time chasing after the complications and never get to the root, then things aren't going to improve for them either. So I really want to help them see that it's possible, that it's important, and that it's possible to do it, even if it's just small ways.

PCO: One of the topics that you're going to talk about is initial interventions that primary care physicians can take to stabilize obesity. I was wondering if you have any tips that primary care physicians can use to help initiate conversations about obesity with their patients? That initial conversation can be quite difficult sometimes.

Christensen: It can be quite difficult. And that's another area where nobody gets any education, right? We're not taught how to bring that up. And what's different about obesity than other conditions is that it's mired in so much bias and stigma that clinicians are either afraid to bring it up because they don't want to offend the person, or the person shies away from it. You know, the patient, because they've had so many bad encounters.

So, one of the most important tips about raising the issue of obesity that's different than other conditions is that we want to ask their permission. "Do I have your permission to discuss your weight? Would it be all right if we discuss your weight?" Now, that's very different than other conditions, right? We don't ask someone, "Would it be okay if we talked about your A1c?" Or, "Would it be alright if we talk about your LDL or your blood pressure?" Those are not conditions that are mired in the bias and stigma that obesity is, and most people by the time they encounter a clinician have had some really significantly biased and negative encounters with health care. All areas of health care, as well as society, employment, and all those other places. So, to develop a partnership by conveying respect of that person's desire to talk about it with the clinician is really important. And that act alone can really build a lot of goodwill and be the beginning of a really productive partnership on the topic. So that's a great way to do it.

And there can be other strategies that can be used, like, "we screen all our patients for weight issues and your screen was positive today. Would it be alright if we discuss your weight?" So there's different ways to bring it up, but a lot of it is conveying respect and tenderness and compassion, rather than being judgmental.