Managing Weight Conversations in Non-White Patients
You are nearing the end of a busy clinic day and your last patient has just been checked in. This is a review of a new patient with a middle aged black woman who is new to the area. Typically, you find these visits energizing, but a quick review of medical history and vital signs leaves you a bit apprehensive.
This patient has several chronic medical conditions, including hypertension, osteoarthritis of the knees and prediabetes, as well as a body mass index (BMI) of 38. Good, you think, if this patient could lose weight, it would solve all her problems. However, you pause for a moment because you’ve overheard other people in the practice mentioning that their patients of color are less interested in treating obesity.
Some have speculated on the reason for this, but you don’t know if it’s true based on your personal experience. Nevertheless, you have noticed that your patients of color are less likely to seek your advice on weight management. Is it because you don’t highlight it for fear of offending someone from a different cultural group? Uncertain and cautious, you choose not to talk about it. Did this moment of discomfort create a missed opportunity to tackle obesity and its complications?
Body weight and even the term “obesity” are tense discussions for many healthcare professionals and patients. Obesity is visible, while many other chronic diseases are not. Our society has stigmatized weight with inherent assumptions about character, intelligence, worth and work ethic. Weight is also associated with personal aesthetics and is subject to constant criticism from self, friends, family and society.
With all this baggage, it’s no wonder that many healthcare professionals avoid the subject with their patients. However, avoiding the topic does a disservice to patients and, from a health equity perspective, people of color who have higher rates of obesity are at an even greater disadvantage in efforts to to achieve a state of health and well-being.
Discussing body weight with patients is complex
The complexities of discussing body weight with your patients of color are many. Some members of communities of color, such as black people, may have different opinions about what healthy body weight and attractive body size look like. It is often traditional perspectives that value large body sizes as a sign of wealth, power, and health. This perspective can apply to all stages of life, from young children to older adults, and conflicts with many mainstream medical paradigms that show clear associations between higher body weight and increased risk of health problems. health.
Patients of color may also understand some of the nuances of excess body fat enough to dispute that BMI applies to them because BMI does not take into account the distribution of body fat, understanding that the worst health outcomes are associated with central adiposity versus peripheral adiposity. This makes discussion of the concept of obesity more difficult.
Using culturally competent care concepts in the context of understanding obesity as a chronic disease can help overcome these challenges and enhance one’s sense of self-efficacy to initiate conversations with patients from all backgrounds and identities.
A culturally competent approach increases the likelihood that the patient feels heard in the discussion rather than experiencing a one-way exchange. Additionally, patients are likely to be more involved in shared decision-making, which will increase the likelihood that treatment will be initiated. Finally, patients will learn that this concern is primarily about their health and not a judgment of character or appearance, as is unfortunately the case for many of our obese patients.
If healthcare providers don’t lean into this conversation with their patients from different backgrounds, we will continue to see the growing obesity disparity. We can use the 5As framework (Ask, Advise, Assess, Assist and Arrange) as a tool for health care providers to provide culturally appropriate care. This can make conversations about obesity and treatment more meaningful for the patient and less anxiety-provoking for the clinician. The 5 As are a good starting point to guide discussions about chronic conditions that require patient engagement and involvement in optimizing the treatment plan and its implementation.
Most clinicians are familiar with this smoking cessation counseling framework, where clinicians can ask permission to discuss smoking cessation. If the patient confirms, the clinician then informs him of the health risks associated with tobacco use. The clinician then assesses the patient’s interest in quitting smoking. Finally, the clinician assists in offering resources or treatment consistent with goals and arranges follow-up to review progress.
Using the 5 A’s for obesity is not much different from what one might do when counseling to quit smoking. However, there are ways to improve cultural competence using this obesity-specific framework. The first step is to recognize your own bias and how it might influence your assumptions and interactions. This can be difficult to determine because no one wants to believe they have a bias, but we all do to varying degrees.
Bias in the context of obesity care can manifest itself in many ways, including how you recommend certain types of treatment. We make other assumptions as a matter of routine. For example, looking at the new patient assessment scenario we started with, most would probably assume that the patient gained weight to reach their current BMI of 38. However, have you considered that the patient might already be engaged in active treatment and could have lost weight to reach this BMI, representing a healthier state?
The next consideration is to expand What you ask. Instead of just asking about the patient’s weight, it would be better to ask what the patient thinks about her weight and her health. This introduction creates an opportunity to learn more from the patient’s perspective while limiting the ability for the clinician to start with their own beliefs and perspectives. Additionally, the clinician can explore body image preferences and avoid assumptions based on race or self-identified appearance that border on stereotyping. Understanding the patient’s values, belief systems, and core elements of identity will help navigate the treatment discussion in a thoughtful, patient-centered way.
Additional considerations for other components of the 5As include counseling the patient about the link between obesity and other chronic diseases and assisting the patient with social support.
Many people from backgrounds where heavier body sizes are preferable may not have a clear understanding of the associated health risks. Linking the biology of weight regulation to common health risks can be a vital part of educating the patient about why you are concerned.
It also provides an opportunity to let the patient know that improving health or preventing disease does not require achieving a “normal” BMI, which may be difficult for many or undesirable as a personal goal. . For example, stating that a 10% to 15% weight loss can lead to remission of type 2 diabetes or significant reductions in blood pressure, but is unlikely to lead to adverse body image, can reconcile discrepancies the patient may feel (ie, “I want to be healthier but I like my curves”).
If the patient is reluctant to engage in treatment, the counseling stage is where this hesitation can be translated into goals of preventing weight gain as well as improving nutrition and physical fitness. Assisting the patient in a culturally competent way may include considerations of family and social dynamics that may influence patient engagement and social support.
Patients of color undergoing treatment for obesity may have to generate social support outside of their normal social networks. They may also need to explain to friends and family what they are doing and why they are doing it. As a result, many patients may not wish to tell others about their weight management treatment, leading to social isolation. Providing social support resources in the community or trusted online sources can help reduce some feelings of isolation.
Having conversations with your patients from different cultural backgrounds about their weight doesn’t have to be scary or intimidating. In many cases, you are not the first healthcare professional to talk to the patient about weight. However, you can be the one who does it in a thoughtful, engaging, and impactful way.
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