5 minute read

Heart disease and cancer continue to be the biggest leaders for US deaths in 2020.¹ Heart disease led the way at 650,000 while cancer was just shy of 600,000. One common risk factor is obesity which is also correlated with the development of other diseases such as type II diabetes and hypertension. Obesity has become an epidemic in its own right. Its incidence among adults was 10% in 1960, 38% in 2014, 40% in 2018, and is now expected to rise to 50% by 2030.⁴ Although obesity is highly prevalent, one study found that only half of those who were overweight considered themselves to be overweight.⁷ Shifting social norms regarding desirable and acceptable body types present challenges to practitioners who wish to discuss metabolic health with their patients.

Body weight is a sensitive subject for many people. A patient who does not identify as an obese person but is told by their practitioner that they are obese may perceive the revelation as an affront. Other patients may perceive obesity as a non-serious condition, perhaps even ordinary as it is commonplace in certain regions or communities. The complications associated with obesity warrant meaningful communication about patients and their body weight. If a direct approach seems ill-suited for a particular patient, certain strategies can be used to establish patient rapport in discussing obesity or overweight conditions. The strategies will be discussed in further detail but first let’s review the risk factors associated with obesity.

Diets high in trans fats and saturated fats stimulate the liver to release LDL into the bloodstream. Plaque builds up in the arteries and atherosclerosis ensues.³ Authors of one study looked at 300,000 people without heart disease who were normal weight, overweight, or obese based on their body mass index (BMI). After four years, researchers found a direct correlation between higher BMI and a higher risk for heart attacks, strokes, and high blood pressure.²

Obesity has factors related to the promotion of cancer as well. Alcohol stimulates production of reactive oxygen species and alcohol itself is converted to acetaldehyde. These two compounds are direct mutagens which are responsible for the initiation of cancer by mutating proto-oncogenes and tumor suppressor genes. Patients who frequently consume alcohol accelerate their risk for oropharyngeal, esophageal, laryngeal, breast, colon, rectal, and liver cancer. Excess fat cells produce estrogen and various cytokines that induce inflammation (a direct mutagen), angiogenesis (supports tumor growth), and cell migration (supports metastasis). Currently, obesity and diet contribute to cancer incidence as much as tobacco and smoking.⁵

Excess adipose tissue also releases increased amounts of non-esterified fatty acids, glycerol, hormones, pro-inflammatory cytokines and other factors involved in the development of insulin resistance. There is a significant amount of evidence that supports the urgency to treat excess body to prevent costly (financial and debilitating) complications.

As a healthcare provider prepares to segue into a discussion about the patient’s weight, the provider should use language that is respectful to the patient’s concerns. Scott Kahan, MD, MPH, medical director of the Strategies to Overcome and Prevent (STOP) Obesity Alliance at George Washington University, demonstrates a method he has found successful for leading into talks about a person’s weight. “In my experience, asking permission is an extremely valuable strategy, and this is coming from a doctor who specializes in obesity. Every single patient who comes into my office is explicitly asking for my help around weight management, yet when we start talking about weight, I always start by asking if it’s okay to talk about it.”⁶

In subsequent discussions nonjudgmental, neutral language should be used such as refraining from calling the patient “obese” directly and instead stating, “a patient with obesity” or “a patient who has obesity”. Interviewing style should be collaborative in nature rather than interrogative. Obesity is a multifactorial problem that requires behavioral changes. The variety of factors that could possibly contribute to a patient’s obesity requires the need for communication that is forthright. Behavior management to prevent or reverse obesity may involve deeply ingrained habits. Weight management should be looked at as a long-term working relationship.⁶ By using language that conveys discreet respect for the patient, we hope to start a dialogue about body weight which, over multiple visits, will develop into an effective weight control plan endorsed by both the healthcare provider and the patient.

References

1. Ahmad FB, Anderson RN, Cisewski JA, Minino A. Provisional Mortality Data — United States, 2020. Centers for Disease and Control and Prevention. https://www.cdc.gov/mmwr/volumes/70/wr/mm7014e1.htm. Published March 31, 2021. Accessed April 1, 2021.
2. Anderson J, Celis-Morales CA, Gill J, Gray SR, Iliodromiti S, Lyall DM, Mackay DF, Nelson SM, Pell JP, Sattar N, Welsh P. The impact of confounding on the associations of different adiposity measures with the incidence of cardiovascular disease: a cohort study of 296 535 adults of white European descent. European Heart Journal, 2018; DOI: 10.1093/eurheartj/ehy057
3. Can we reduce vascular plaque buildup? Harvard Health Publishing. https://www.health.harvard.edu/heart-health/can-we-reduce-vascular-plaque-buildup#:~:text=Plaque%20forms%20when%20cholesterol%20lodges,a%20cap%20over%20the%20area. Published May 3, 2019. Accessed April 1, 2021. 
4. Carroll MD, Fryar CD, Hales CM, Ogden CL. Prevalence of Obesity and Severe Obesity Among Adults: United States, 2017–2018. NHCS Data Brief. 2020;360. https://www.cdc.gov/nchs/data/databriefs/db360-h.pdf. Accessed April 1, 2021.
5. Compton C. Cancer: The Enemy From Within. Scottsdale, AZ: Springer; 2020.
6. Seaborg E. Advise & Consent: Talking to Obese Patients About Their Weight. Endocrine News. https://endocrinenews.endocrine.org/advise-consent-talking-to-obese-patients-about-their-weight/. February 2016. Accessed April 1, 2021.
7. Swift A. Fewer Americans in this decade want to lose weight. Gallup. https://news.gallup.com/poll/198074/fewer-americans-lose-weight-past-decade.aspx?g_source=Well-Being&g_medium=newsfeed&g_campaign=tiles. November 2016. Accessed April 1 , 2021.