Clinician-patient communication lacking in primary care management of obesity
BOSTON — The approaches currently used by primary care providers to manage obesity are not sufficient, according to a presentation at the annual Cardiometabolic Health Congress.
Martha Funnell, MS, RN, CDE, associate research scientist in the department of learning health sciences, University of Michigan Medical School, Ann Arbor, emphasized communication as a key area for improvement — but acknowledged it isn’t easy.
“When your patients come to you and want to lose weight, they’re really looking for a magic potion,” Funnell said. “They want to keep doing exactly what they’re doing, eating exactly what they’re eating, getting no more exercise than they were, and somehow magically lose weight.”
Health professionals, too, are typically trying to find magic words they can use in the course of a 10-minute visit that will help patients make healthy choices and change their lifestyle.
“Telling patients to ‘lose weight and exercise’ are not four magic words,” Funnell said. “That doesn’t work, it’s not education, and it’s not weight loss counseling. It’s simply telling people what they already know.”
Funnell provided some insights and evidence-based alternatives for helping patients lose weight.
Current evidence does not support the use of low- to moderate-intensity physician counseling, Funnell explained. “It really just doesn’t work very well for clinically meaningful weight loss.”
Primary care provider counseling plus pharmacotherapy or intensive counseling from either a dietitian or a nurse has been shown to be more effective, particularly when meal replacements are used.
She pointed to guidelines recently released by the American Society for Behavioral Medicine and published in JAMA that offer the “5 As” model to guide the management of obesity in primary care as an effective framework. They are: assess, advise, agree, assist and arrange.
“It’s all about relationships and communications,” Funnell said. “It’s coordinating a team to address the psychosocial, medical and psychiatric issues — keeping in mind most of the issues are not medical they’re psychosocial — providing counseling, including a variety of strategies, and helping patients to connect with community resources.”
In terms of advising, Funnell noted most people understand they need to eat better and exercise more — and if they could they would.
“A lot of it is helping people figure out the ‘how,’” she said. “People have some ideas about what, but they don’t know how to do that in the course of their busy lives and competing priorities.”
Providers need to personalize both interventions and information, she said.
“Part of it is saying, ‘here’s why I’m concerned about you,’ not just ‘you need to lose weight and exercise because you’re at risk for these things.’”
A spirit of cooperation
Regarding agreement, Funnell said both clinicians and patients need to come to an understanding about an individual’s plan, which should include both self-monitoring and self-directed goal setting.
“Self-monitoring includes keeping track of weight, exercise and food intake. More frequent monitoring is consistently associated with greater weight loss.”
Technology-based forms of monitoring often seem more acceptable, but are no more effective. There’s “nothing magic” about technology; patients benefit from a format that is easier for them use, according to Funnell.
“It’s important to help patients set reasonable and realistic goals … and to help patients recognize it took them a long time to gain 50 pounds, and they’re not going to lose it in a week and a half.”
Self-directed goal-setting is focused on patient priorities, Funnell explained. She shared some questions she often asks patients: “How is your weight a problem for you?” “What are you struggling with?” “You’ve tried several times to lose weight. What’s hard for you? What happens? What goes wrong?”
When it comes to assisting, Funnell said providers can help patients figure out the point at which they get derailed. She said this entails helping patients learn their triggers and find options to deal with stress other than food.
Expressing the real challenge involved in losing weight is also essential, Funnell said. “When we talk to patients about weight loss, let them know that it’s hard, that it’s a struggle, that it’s frustrating because often you don’t see the results as quickly as you would like.”
She highlighted consensus from a recent NIH conference that providers encourage patients to lose the first 10% and then stop for several months, rather than plateau and become frustrated.
Assisting might also include helping patients plan, develop new ideas and maintain an attitude of confidence in themselves, Funnell said.
Providers can say “try something out. If it doesn’t work, it doesn’t mean you’re a failure or a bad person — it just means that you can learn something from that experiment.”
Essential to the arranging aspect of the model is evaluating patient progress as well as following up on referrals to programs.
“We need to help patients find … nutrition services, behavioral and mental health services, education or even prevention programs,” Funnell said.
What works, what doesn’t
Part of connecting with resources may include technology, on which the data are mixed because not all use recommended behavioral strategies. But Funnell said clinicians and patients can look for apps based on programs or strategies proven effective.
“There are also programs we know work and have been shown to be useful for prevention, reinforcement, self-monitoring, communication and social support, with varying degrees of success,” she said. “We know if you recommend that patients use these resources, they do better. We also know this is clearly going to continue to grow. Technology is the way of the future.”
Funnell said the DPP is working to spread its program — available online and through the physical community, often YMCAs — across the United States. Covered by more than 20 health plans, approximately 30,000 people have used the program so far, with an average weight loss of 4.6%, she said.
Funnell closed her talk by noting “the biggest single problem with communication is the illusion that it has taken place.”
Motivational interviewing is a communication strategy providers may find helpful when managing patients with obesity, though it does require formal training. It involves asking open-ended questions, affirmations and reflective listening.
“Some people who say they’re doing motivational interviewing are actually just saying the same thing only they’re trying to say it a little louder,” Funnell said. “It’s not designed to motivate people. It’s designed to help people determine their own motivation. It can work, but it takes time, and it’s not magic.”
She also pointed to empowerment-based studies conducted in patients with diabetes over the last 20 years that used slightly more simple communication strategies — asking open-ended questions, actively listening, helping patients to reflect on their answers, and offering empathy and encouragement.
“I wish it was easier than communication,” Funnell said. “At the end of the day, that’s really what it comes down to, and that’s what works. Words are our most inexhaustible source of magic.” – by Allegra Tiver
Funnell M. Behavior Change: From Compliance to Collaboration. Presented at: Cardiometabolic Health Congress; October 21-24, 2015; Boston.
Disclosure: Funnell reports no relevant financial disclosures.