Rates of obesity have been steadily rising over the past 3 decades in both adults and children. Today, more than one-third of American adults and about 17% of children and adolescents, ages 6 to 19, have obesity.1 Cancer rates have risen in tandem with obesity rates, making obesity the second greatest environmental risk factor for developing cancer after smoking. In addition, being overweight or having obesity also increases cancer survivors’ risk of recurrence. (See “Tackling the Obesity and Cancer Epidemic,” in the May 25, 2017, issue of The ASCO Post.)
Yet, for myriad reasons, discussions about weight and health are difficult to initiate with patients and are fraught with apprehension both for patients, who may feel shame and embarrassment about being judged by their health-care providers, and for oncologists, who may worry about offending their patients by raising the topic of weight. However, there are strategies for breaking down the barriers to having productive conversations about weight and health, including using effective language and instituting a safe and trusting environment where patients can feel comfortable discussing their weight.
The ASCO Post talked with William H. Dietz, MD, PhD, the Sumner M. Redstone Center Chair at the Milken Institute School of Public Health at George Washington University in Washington, DC, and Director of Strategies to Overcome and Prevent (STOP) Obesity Alliance, about the language to use for more effective patient-centered communication regarding weight and health, how to start the conversation with patients, and how to eliminate physician bias against patients with obesity.
Focus on Person, Not Condition
What is patient-centered communication, and what terms should oncologists avoid and which ones should they use when discussing weight and health with their patients with obesity?
The conversations about obesity at both the public and patient level begin with using people-first language to eliminate generalizations and stereotypes by focusing on the person rather than the condition. For example, we routinely refer to a person with obesity as “an obese person” rather than a “person with obesity,” and when we use that language, obesity becomes that person’s identity instead of who that person is. He is obese; he is not a teacher, he is not a parent, he is not an accomplished person, and that language reflects a fundamental bias because we don’t use those terms when talking about people with other diseases.
Obesity is not something that happens overnight as the result of an active decision.— William H. Dietz, MD, PhD
We don’t refer to a person with cancer as a “cancer person” or a person with disabilities as a “disabled person,” and the same should apply when describing a person with obesity. Obesity is a condition or a disease and not an identity. In studies of adults and pediatric patients with obesity, when asked what terms they prefer their providers use to describe their condition, they said they preferred terms like “overweight,” “unhealthy weight,” “healthier weight,” or “increased body mass index.” The word “fat” as a descriptor is anathema.
The same is true for words like “diet” and “exercise,” because they both indicate deprivation and are off-putting. Instead, using terms like “eating habits,” “better choices,” or “physical activity” when physicians are counseling patients about their weight are preferred.
Beginning the Conversation
Having weight-related discussions with patients can be difficult. How can oncologists begin the conversation with their patients?
The topic of weight is a very personal issue and often a sensitive one that patients may have struggled with for many years. An oncologist who begins the conversation with “You have a weight problem and need to eat better and be physically active” is not telling the patient anything new, and it sounds judgmental.
A preferable way to begin the conversation is with an open-ended question, such as, “Are you concerned about your weight?” If the patient responds, “No. I’m not concerned about my weight. My cancer is a much bigger problem for me.” The oncologist can then explain how weight factors into poorer outcomes for patients with cancer and increases their risk for cancer recurrence.
In this way, the oncologist is giving the patient feedback and is sharing information with the patient, but he or she is not doing it in a judgmental way, but rather is engaging the patient in the conversation. For example, the oncologist could say, “I’m concerned about your weight and its potential contribution to the course of your disease,” which expresses the provider’s concern.
Physician and Patient Barriers
What are some of the barriers to providing patients with resources to help them manage their weight and increase their level of physical activity? And what are the barriers preventing patients from addressing their excess weight?
Lack of time, knowledge, and reimbursement all contribute to a provider’s frustration or inability to deal with the issue of obesity. We have done repeated surveys of primary care physicians, nurse practitioners, obstetricians/gynecologists, and family practitioners about their knowledge regarding obesity treatment guidelines. Our most recent one showed that only 49% of health-care providers knew the physical activity recommendation from the Centers for Disease Control and Prevention is 150 minutes per week.2 Only 30% of respondents knew that a variety of diets, such as the Mediterranean diet, could be used in the treatment of obesity, and just 16% were aware that 16 or more visits for weight loss are required for adequate weight-loss therapy.
Recognizing that oncologists may not have the training necessary to guide their patients in weight management strategies, having a list of resources handy, such as Nutrition.gov and LIVESTRONG at the YMCA (www.livestrong.org/what-we-do/program/livestrong-at-the-ymc), to give to patients or providing patients with referrals to a nutritionist or a behaviorist is helpful.
Understandably, some oncologists and patients may be reluctant to bring up the topic of weight, because the main concern is curing the patient’s cancer. The cancer is the acute problem and deserves the focus of attention, but right after that is the concern of cancer recurrence; increasingly, we recognize that weight contributes to disease recurrence. It is important to recognize there is both an acute problem and a chronic problem with cancer and weight.
Patient Stigma and Physician Bias
Please talk about the stigma patients feel around weight issues and physician bias in treating patients with obesity.
It is true that physician bias is a factor in how a provider approaches an overweight patient or one with obesity. Obesity is among the most stigmatized conditions in our society and ranks up there with racial discrimination. A patient’s experience with providers and the sensitivity of providers to the patient’s problem often predict how well that patient will follow up with that provider for care. If patients feel providers are blaming them for their obesity, they are very unlikely to follow through with those providers for treatment.
It may differ in an oncology clinic, where the primary focus is treating the cancer, but we know that patients with obesity are much more reluctant to encounter providers or solicit medical care because of their experience in the health-care system and the kind of bias that providers hold.
And providers’ view of obesity may shape the care they provide. There have been studies that show if providers understand obesity is a complex problem and is a consequence of a variety of complicated factors, including an interaction of patients’ genes with an obesogenic environment, they tend to be less judgmental than providers who feel that obesity is the patient’s fault.
It’s important to remind all health-care providers that people just don’t decide to develop obesity on their own. This is a long process for many people, and it’s not something that happens overnight as the result of an active decision. ■
DISCLOSURE: Dr. Dietz is Director of the STOP Obesity Alliance and is on the scientific advisory board of Weight Watchers.
1. National Institute of Health, National Institute of Diabetes and Digestive and Kidney Diseases: Overweight & Obesity Statistics. Available at www.niddk.nih.gov/health-information/health-statistics/Pages/overweight-obesity-statistics.aspx. Accessed June 2, 2017.
2. Centers for Disease Control and Prevention: How Much Physical Activity Do Adults Need? Available at www.cdc.gov/physicalactivity/basics/adults. Accessed June 2, 2017.