ORLANDO — Successful weight loss begins with a conversation that many clinicians never have with their patients, a primary care obesity specialist said here.

Obesity has become widely recognized as a disease, but many clinicians and patients still do not approach the condition as a disease. Existing in medical and social environments of bias and stigma, many patients with obesity continue to blame themselves for the condition and consider it their responsibility to deal with the problem, said Angela Golden, DNP, FNP-C, of NP Obesity Treatment Clinic in Flagstaff, Arizona, during the American Association of Nurse Practitioners meeting.

The ACTION study, one of the largest studies ever conducted in obesity, involved 3,008 patients with a body mass index (BMI) of 30 or greater, and 606 healthcare professionals. The study showed that two-thirds of the patients considered obesity a disease but only 55% had a formal diagnosis, and a similar proportion of the patients did not think obesity affected their future health. Moreover, 82% of the patients said their condition was solely their responsibility.

“Think about that for a minute,” said Golden. “If patients thought cancer was a real disease, do you think that only 18% would think they needed no healthcare assistance with it? What chronic disease is out there that 82% of people living with that chronic disease think it’s their total responsibility to treat it? There is nothing else. This is it. This is the last disease that people think they have total responsibility.”

When asked why patients with obesity do not seek help with weight loss, two-thirds of the healthcare providers said patients are embarrassed to bring it up. More than half said that patients with obesity are not motivated to lose weight and/or do not believe patients can lose weight. Almost half of the providers (47%) said patients are not interested in losing weight.

Interviews with a subgroup of 823 patients in the ACTION study who did not seek help with weight loss revealed a different story: 15% said they were embarrassed to talk about their condition, and 21% said they were not motivated to lose weight.

Research has shown that “weight stigma” undermines a person’s health by contributing to obesity, metabolic disorders, psychological disorders, and mortality. Another recent study showed that weight bias and stigma adversely affect the approach to clinical management of obesity, limit reimbursement, inhibit patients with obesity from seeking healthcare, and ultimately contribute to increased morbidity and mortality.

The bias extends into health insurance coverage, said Golden. Employers that offer health insurance have a choice to opt in for coverage of obesity. Insurers often classify drugs used to treat obesity as “vanity” drugs. A GLP-1 agonist to treat diabetes is not considered a vanity drug, but when the same drug is used to treat obesity it is, she said.

“That’s bias in our healthcare system,” said Golden. “What does that mean? It keeps patients from seeking healthcare. There are 13 obesity-related cancers whose rates are rising in the United States. One of the reasons they’re rising is that patients don’t go get preventive care because of the bias and stigma they have had toward them in the healthcare environment. That results in their cancer being diagnosed later, and we get higher mortality and higher morbidity.”

Weight stigma and bias often shut down the necessary conversation between the healthcare provider and the patient with obesity before it even starts.

“I will never forget the day that I sat in a room with my father for one of his visits,” said Golden. “The [medical assistant] did his height, but she didn’t even put him on the scale. My dad had severe disease. He probably weighed close to 350 pounds. All she asked him as she backed out the door was, ‘Russell, do you have diabetes?’ ‘No.’ ‘OK, thank you.’ My dad looked at me and asked, ‘Do you think she even saw me?’

“I know why she didn’t weigh him,” Golden continued. “She was afraid the scale wouldn’t go that high. I don’t think she did it out of mal-intent, but that kind of stigma is really why this is a disease like no other. We have to have the conversation about how to have that conversation with people.”

The conversation begins with the clinical environment. An office with a cramped arrangement or furnishings that fail to take into account the physical attributes of the clientele can be intimidating or lead to encounters that are uncomfortable or embarrassing for patients with obesity. Patients should find the clinical environment safe, accessible, accommodating, comfortable, welcoming, and non-shaming, said Golden. That includes waiting-room reading materials that focus on health habits, for example, as opposed to the latest diets and “being thin.”

The same qualities should extend to exam rooms. If a patient needs to disrobe, extra-large gowns should be readily available. Scales should be placed in a discreet area and have a capacity greater than 400 pounds. Toilets also should be designed to accommodate large individuals. Examining tables should be sturdy and wide, and a similarly study stool or steps with handles should be available to assist patients onto the table.

Large patients often are not considered when medical devices are purchased. Devices should include extra-long needles to facilitate blood draws, large or long vaginal specula, urine specimen collectors with handles, and a tape measure at least 72 inches long.

Language opens the door to a successful discussion about obesity. Golden said she would like to normalize the term obesity to remove the stigma and bias associated with it. In fact she would prefer to eliminate use of the term altogether and goes so far as to advocate for that with dictionary publishers. She argues that obesity is a term that is often whispered in much the same manner as when mental health was surrounded by greater stigma and bias in years past.

To encourage conversation with patients who are obese, Golden recommends use of terminology such as overweight, increased BMI, unhealthy or healthier weight, eating habits, and physical activity. Words that can discourage conversation, she says, include fat, diet, and exercise, as well as obese.

Borrowing from published work, Golden suggests a conversation based on the 5As:

• Ask for permission to discuss weight
• Assess BMI, waist circumference, and obesity stage
• Advise about health risks of obesity and benefits of weight loss
• Agree on reasonable expectations and targets
• Assist the patient in identifying barriers to optimal health

“American needs all providers to start treating this disease and its complications,” said Golden. “Be sure your practice is a safe harbor. Begin the conversation and assure the follow-ups are occurring. Above all, understand the bias people with obesity face.”

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