Physician Perspective: Talking to Patients Regarding Obesity

Thanks so much for joining us. I'm here today with Anastasia Amaro, one of our endocrinologists at Penn. Um, I'm Alexis Ogdie. I'm a rheumatologist and epidemiologist at Penn. I treat psoriatic arthritis in particular, and we've been thinking a lot about obesity uh in psoriatic disease. Anastasia, her specialty is obesity. So, can you tell us a little bit about you and what your practice looks like and then we'll dive into our question today.

Excellent. Thank you, Alexis, for having me. I am an endocrinologist and obesity medicine specialist. Um, I direct a center for non-surgical weight management center here at Penn. So, we do all kinds of obesity management um in in people with and without rheumatological conditions, in people with cardiovascular disease and without it. So, obesity and um complications of bariatric surgery if um um people have them.

Great. Well, so one of the questions that we as rheumatologists are always getting stuck with is how do we bring up obesity with our patients? And actually, as I talk about obesity and psoriatic disease, this is one of the most common questions I get from other rheumatologists. I'm really nervous to bring it up. Patients sometimes have a bad reaction to it. Um in general, let's back up before you even address that question. What do you want to tell other specialists that are not obesity specialists about talking to patients or considering obesity in their patients?

Thank you. Very good question. So I I think I would like to go into briefly into two different directions. So one direction is not really involving the patient yet. Just a message to non-obesity medicine specialties. The problem with obesity — one of the uh challenges we have studying obesity is that obesity has been severely undercoded. So we we can recognize obesity as clinicians but we don't put it on paper. We don't assign a code to it for many different reasons. We can dive into them but not necessarily so. But if there is no code [clears throat] um health um studies are very difficult to conduct in — it's difficult to um convince third party payers to participate in patient care if obesity is not listed as the chronic disease. So I would urge and I would ask non um obesity medicine specialists and primary care physicians to to incorporate diagnosis of obesity in their portfolio. Diagnosis is simple. It's actually E66 I think and and and and that's it and couple — they're just up to the dots. You can select nonspecified. That's totally fine. But that E66 will get a whole lot of information for public research, public health research. Please use your problem list and and make sure to diagnose it.

I think that's actually a really important point — making sure that you're calling it out for the patient and the people taking care of them and you're calling it out as a problem. So you put this ICD code in, what are we telling the patient about, or how are we going to talk to the patient about it?

Exactly. So this is — yeah, this is a very good question. So you put something on, then patients may not be happy if you don't discuss it. So the way I I address it in the in the first place, at the moment where I have to code for example — and this is the first kind of — this is where the conversation begins — I say well um your body mass index is 32 and that's what is defined currently in our vocabulary as obesity. Would it be okay with you if I put it on your chart? So um overall approach to breaking ice about any new condition would be ask-tell. So first kind of you're asking for permission. They say okay put it on. If they say don't, I don't want to go there, you're done — pretty much you cannot force things onto someone, right. But if they say okay yeah I'm fine, so it's actually I'm glad you bring this up, then it opens up uh an opportunity to say something else, right. So that's your opportunity to to make a statement and then of course you know the patient — let's say it's not a new patient for you. So you have established relationship, you know their kind of level of their own engagement in their healthcare. So you can make a more or less scientific statement outlining the problem, saying something like um excess weight is associated with um difficulties treating arthritis, or um we have seen that weight loss has helped people with with their joint pain. So something that you can expand on scientifically if patients so desire. So if you catch their attention then the next question — the next after the statement — the next ask — would it be okay if we discuss your weight in the context of your rheumatologic condition. So I I think this is a very simple tool and if we um train yeah ourselves and each other it it makes it — it will help us a great deal.

I love that it's so simple — ask-tell — and yet I don't do it very much. I think I — you — I do the tell then ask, which I really like that as an opener though. Um the general way I have done it is when a patient is not doing so well on therapy I might say can we talk about the other i
guess maybe I'm asking about it. Maybe I say, "I'm going to tell you a little bit about the other things that may contribute to your — um — lack of — to this therapy not working as well as it is." Or maybe let's explore some other ways that we can maybe get you feeling better. And then that's where I'll talk about anxiety, depression, obesity, other things and say maybe we can pull on this string a little bit and can we talk about that a little bit more. I think I probably too often do the statement rather than a question. So I think that's a really great point.

And a great — you do it, you know it. I think it's hard to kind of start from a question from like out of nowhere. It's still going to be a continuation of your previous discussion, you know, so it's not going to be the opening paragraph of your encounter. So it's probably naturally coming to that — so statement, question, statement, question. So yeah, that's a great point.

Well, I think that's actually a great thing to leave people with — so ask, tell — think about the questions in there, and that opens the door for more discussion. And like you said, many patients want to talk about this and they're just waiting for the opening.

Actually, one specific anecdote is you and I were just on a different meeting earlier today and one of the patients said, "I was nervous to raise it with my doctor." And to me, that kind of blew me away a little bit. I was like, "What — where are the people you're supposed to ask?" Like, so — but they don't always know that. So asking will open the door for them to be comfortable with that. And I have seen that several times in practice, too.

So yeah, that's absolutely right. And so even probably if you'd like to continue in the topics of different language used in our medical records and in our communication with the patients — it's probably kind of what I find helpful — is going away from, you know, standards from, well, "it would be nice to lose weight and reduce calories or increase physical activity." Nobody knows what that means and they've seen it and heard it so many times that I doubt a sentence like this would cause anything but resentment.

So, you know, being specific is better than a general statement. So if you have the bandwidth, if you have the extra two minutes, select one thing and make a specific comment. If there is no specific recommendation you feel comfortable about, make another scientific statement to kind of keep people engaged, or have them reflect on what they do, or have them do a Google search or an AI search in a more strategic way after speaking with you. So yeah, any kind of specific — and going away from generics.

Perfect. Any last thoughts you want to leave our rheumatologists — or any of our listeners — with? Rheumatologists specifically.

One more thing you can do — and it could be an introductory statement in all of those conversations. Actually, for people who used to receive steroids, you can acknowledge that steroids may have affected their metabolism, or may have affected their appetite, or may have affected their weight. Therefore, do you mind if we talk about metabolism and weight? So, kind of admitting that steroids have done some — well, they were a necessary evil, but they may have affected the patient's metabolism. So it also may take a little bit of that guilt sensation away — that it's going to be all about their discipline and routine. It's not about discipline. And it's not about willpower. We're going to talk about obesity as a medical condition. We're going to talk about obesity as a disease. It's not going to be a talk about willpower.

Perfect. I think that is a great place to leave our rheumatologists. So to summarize — we talked about making sure you're making a diagnosis, code it. Number two is talk to your patients about it and use the ask-tell approach. Use a scientific statement or something that's going to pull them in, and maybe use the experiences they've had — like a history of glucocorticoid therapy — to say, "We know this is hard. This is not a willpower thing. This is your metabolism. Can we talk about how this might influence your disease?"

So, thank you so much, Anastasia, for joining me today. And thank you to our listeners. Thank you.