Managing Conversations About Weight in Non-White Patients

You're almost toward the end of a busy clinic day, and your last patient was just checked in. It's a new patient exam with a middle-aged Black woman who is new to the area. Typically, you find these visits energizing, but a quick review of the medical history and vitals leaves you feeling a bit apprehensive.

This patient has several chronic medical problems, including hypertension, osteoarthritis of the knees, and prediabetes, along with a body mass index (BMI) of 38. Well, you think, if this patient could lose some weight, it would solve all her problems. However, you pause a moment because you've heard others in the practice mention how their patients of color are less interested in obesity treatment.

Jamy D. Ard, MD

Some have speculated as to why that may be, but you're not sure if it's true on the basis of your personal experience. Nevertheless, you have noticed that your patients of color are less likely to ask your advice about how to manage their weight. Is that because you don't emphasize it owing to fear of offending someone from a different cultural group? Feeling unsure and cautious, you opt not to bring it up. Has this moment of discomfort created a missed opportunity to address obesity and its complications?

Body weight and even the term "obesity" are fraught discussions for many healthcare professionals and patients alike. Obesity is visible, whereas 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 subject to constant critique from self, friends, family, and society.

With all that baggage, it's no wonder that many healthcare professionals avoid the subject with their patients. However, by avoiding the topic, patients are done a disservice, and from a health equity perspective, people of color who have higher rates of obesity are further disadvantaged in efforts to achieve a state of healthfulness and well-being.

Discussing Body Weight With Patients Is Complex

The complexities of discussing body weight with your patients of color are numerous. Some members from communities of color, like Black individuals, may have different views on what a healthy body weight and attractive body size look like. These are often traditional perspectives that value larger body sizes as a sign of affluence, power, and health. This perspective can apply throughout all life stages, from young children to older adults, and conflicts with many of the traditional medical paradigms that show clear associations between higher body weight and increased risk for health impairments.

Patients of color may also understand some of the nuances of excess adiposity enough to dispute that BMI applies to them because BMI doesn't account for the body fat distribution, understanding that worse health outcomes are associated with central adiposity compared with peripheral adiposity. This makes discussing the concept of obesity more challenging.

Using concepts of culturally competent care within the context of understanding obesity as a chronic disease can help overcome these challenges and improve one's sense of self efficacy for initiating discussions with patients from all backgrounds and identities.

A culturally competent approach increases the probability that the patient will feel heard in the discussion rather than experiencing a one-way exchange. Furthermore, patients will likely be more engaged in shared decision-making, increasing the likelihood that treatment will be initiated. Last, patients will hear that this concern is primarily about their health and not a judgement of character or appearance, which unfortunately is the experience for many of our patients with obesity.

If healthcare providers do not lean into this conversation with their patients from different backgrounds, we will continue to see the growing disparity in obesity. We can use the 5 As framework (ask, advise, assess, assist and arrange) as a tool, allowing care providers to offer culturally appropriate care. It can make conversations about obesity and treatment more constructive for the patient and less anxiety-provoking for the clinician. The 5 As provide a good starting place for guiding discussions on chronic diseases that require patient engagement and involvement in optimizing the treatment plan and application.

Most clinicians are familiar with this counseling framework for tobacco cessation, where cliniciansf might ask permission to discuss quitting smoking. If the patient affirms, the clinician then advises the patient about health risks associated with tobacco use. The clinician then assesses the patient's interest in quitting. Finally, the clinician assists in offering resources or treatment consistent with the goals and arranges follow-up to review progress.

Using the 5 As for obesity is not very different from what one might do when counseling for smoking cessation. However, there are ways to improve cultural competence using this framework specific to obesity. The first step is recognizing your own bias and how it might influence your assumptions and interactions. It may be hard to pinpoint because no one wants to believe that they hold bias, but we all do to varying extents.

Bias in the context of obesity care can be exhibited in many ways, including in how you recommend certain types of treatment. We make other assumptions as a matter of routine. For example, in reviewing the scenario of the new patient evaluation that we started with, most would likely assume that the patient has gained weight to reach her current BMI of 38. However, did you consider that the patient could already be engaged in active treatment and might have lost weight to reach that BMI, representing a healthier state?

The next consideration is to expand what you ask. Instead of just asking to talk about the patient's weight, it would be better to ask what the patient thinks about her weight and her health. This lead-in creates an opportunity to learn about the patient's perspective while limiting the potential for the clinician to start with one's own beliefs and perspectives. Furthermore, the clinician can explore body image preferences and avoid assumptions based on self-identified race or appearance that border on stereotyping. Understanding the patient's values, belief systems, and critical components of self-identity will help navigate the discussion on treatment in a thoughtful, patient-centered manner.

Additional considerations for the other components of the 5 As include advising the patient about the link between obesity and other chronic diseases and assisting the patient with social support.

Many people who come 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 may be a critical part of educating the patient on why you have concerns.

This also provides an opportunity to let the patient know that improving health or preventing disease does not require achieving a "normal" BMI, which can be challenging for many or undesirable as a personal goal. For example, affirming that a weight loss of 10%-15% can lead to remission of type 2 diabetes or significant reductions in blood pressure, but is unlikely to result in an undesired body image, can reconcile discrepancies that the patient may feel (ie, "I want to be healthier but I like my curves").

If the patient is hesitant to engage in treatment, the advise step is where this hesitancy can be turned into goals for weight gain prevention along with improvements in nutrition and fitness. Assisting the patient in a culturally competent manner may include considerations about family and social dynamics that may influence the patient's engagement and social support.

Patients of color engaging in obesity treatment may have to generate social support outside of their normal social networks. They may also have to explain to their 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, resulting in social isolation. Providing resources for social support in the community or trusted online sources may help decrease some feelings of isolation.

Having conversations with your patients from different cultural backgrounds about their weight doesn't have to be scary or daunting. In many instances, you're not the first healthcare professional to mention weight to the patient. However, you can be the one who does it in a way that is thoughtful, engaging, and impactful.

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