Obesity: Improving Communication About a Sensitive Topic

Transcript

This transcript has been edited for clarity.

Caroline Messer, MD: Hi. I'm Dr Caroline Messer, and thank you so much for joining me for this Care Cues conversation. I'm here with my long-time patient, Jessica Natale. I first met her many years ago. At that time, she was 5 ft 2 in' and 170 lb.

Technically, according to body mass index (BMI), she was considered medically obese. Now, I really do not like that term. She's obviously been doing beautifully on her weight loss journey. Thank you so much for being with us today.

Jessica Natale: Thank you, Dr. Messer. It is my pleasure being here with you today. And, yeah, I don't like that term either.

Messer: So great — we're in agreement there. We're in agreement on a lot of things.

I wanted to start off the conversation by talking about how practitioners like myself can help facilitate the discussion around difficult topics like weight loss and obesity (though we've just decided we're not going to use that term). Can you tell me how long you've been struggling with difficulty losing weight?

Natale: I think my whole life. I remember myself at I think around 12 or 14 years old — you know, when you're a teenager, you start noticing your body a little better — and I did not like what I saw. I think, emotionally, that was also always something that I struggled with, especially because I have anxiety.

Messer: When you first started meeting with doctors at that time, did they talk to you about some of the underlying causes of the weight? What was their approach, and how do you think they maybe could have done a better job?

Natale: There was never a really friendly approach. I was scared to go in the doctor's office and go on the scale and try to figure out how my weight was. They were always saying that I had to do more exercise or change my relationship with food. They were just, "so you need to change the amount you eat," but they never really talked about how I was feeling about the food or how I was feeling about why I was eating.

Messer: What was it during those interactions that made you feel like it was more difficult to get the kind of care that you needed?

Natale: I think I was feeling ashamed of myself about not being able to achieve the ideal weight. I remember going to a doctor's appointment and feeling so embarrassed — so scared to go on the scale. And I was always afraid that I could be diabetic, or I could have cholesterol problems.

I remember feeling like, why am I not able to do what everybody else is doing? Although I was following diets — so many different diets — and going to gyms and different classes and exercise, that was something that I always struggled when I went to the doctor.

I was feeling that the doctors were judging me because I could not follow what they were saying, even though I was following. But I needed help. I needed options. How do you approach the patient when they come in and they feel the same way?

Messer: When a patient comes in, I say, so when did you first start having trouble losing weight? When did your weight loss journey begin? And sometimes when patients come in, and I know that they're here for weight, I'll still start the conversation with, so what brings you here today? Because I want the patient to bring it up. Then I jump on it. And I'm like, oh, OK. So, I see that you're having trouble losing weight; let me help you.

Natale: When you're trying to lose weight, you do feel that "weight" about you not being able to lose it. And when you come to a doctor's office and they tell you you're obese and your BMI is 31, but you don't feel obese — of course, you feel that you are overweight, but you don't feel obese.

And then when you hear that, you feel, oh my gosh. I really have all this weight. I really need to lose it, and it's very important to have doctors who show you that it's not your fault. It's something else, and you can work on it.

Messer: Even if you've been binge eating, even if you've been emotionally eating — that's not your fault. None of it is your fault. We should not be blaming our patients. No one wants to get to that point. I'm just there to help you and guide you.

I know, as practitioners, we are all so busy. And sometimes it seems like the patient should just trust us because we know all the literature. We've reviewed it. We know what we're talking about. But it's so important to not infantilize the patient, and to really understand that they're adult and they're smart, and to review the different types of weight gain and then all the different options.

There's so many myths out there. I hear all the time, oh, I can't go on the injectables — the incretin mimetics, the glucagon-like peptide 1 (GLP-1) receptor agonists — because I have a thyroid condition. It's not a thyroid condition that's a contraindication. It's if you have a history of medullary thyroid cancer or you carry a gene that puts you at risk. You have a condition called multiple endocrine neoplasia 2 (MEN2) syndrome.

When I meet a patient, I try my hardest, as long as they're a willing partner, to teach them about the medications — exactly what all the side effects can possibly be, but also what all the benefits are. Truly, there are so many more benefits, I think, to medications than we realize in terms of overall health.

Not only do I speak to them about it, I give them handouts. I think when you do that and you take the time to educate properly, you dispel a lot of myths and patients are more willing to listen to you. Was that something that you found useful?

Natale: Yes. It was very important because, at the beginning, I felt that I didn't need the medication. I also was scared and thinking that I could do that on my own. So, I was feeling that the medication probably was not an option for me. But after really learning about it and see all the benefits and how this could help — what this is going to do for me —I think it was very important.

Messer: I really believe in this concept of shared decision-making. I will do my best to discern exactly what the issue is, and then I present you with options. At the end of the day, though, I am not telling you what to do. I am explaining, this is a medication that helps with emotional eating, but it may increase anxiety. So maybe we shouldn't reach for that, but you can try it. Here is a medication that works by speeding up your metabolism. Here is a medication that will help you with hormone resistance.

Once you understand all your options — and you're choosing — of course I'm going to remove anything that's dangerous or contraindicated because that's my job as a doctor. So I explain what you can't do. But then, of the remaining options, I think that if you're helping to make the decision, you're much more likely to stick with it and to believe in it.

Natale: That's why it's very important that you have all this information before you make the decision. I think that just as important as you taking the action is knowing what kind of action you're taking.

Messer: So, while this is not about cosmetics, you obviously look beautiful today.

Natale: Thank you.

Messer: Can you tell us a little bit about your progress, how long you've been seeing me, where you are vs where you began, and whether you think you'll be able to have sustained success?

Natale: I've been seeing you for 2 years now, and I've lost 38 pounds. The important thing about this whole thing is that I'm keeping the 38 pounds off, which is a very good achievement. I'm pescatarian. I don't eat meat. That's something that I completely changed since I started the medication. Thinking about what I'm eating and what my body really needs is what changed for me.

Messer: Jessica, you've done such an incredible job changing your whole lifestyle: your exercise, your diet, your approach to mental health, and, certainly, your relationship with food.

Natale: I'm really, really happy with how this treatment is going, and I'm really happy that I have all your support.

Messer: I cannot thank you enough for opening up. I know it's hard to do, especially in front of a big audience. Thank you so much for joining me today. It's been such a pleasure getting to know you well.

Natale: Thank you, Dr Messer. It is my pleasure, too. Thank you.

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