I struggle with how to discuss the topic of weight with patients. I also struggle with how to discuss it here on my blog. I have dozens of half written posts litering the notebook app on my iPhone. I decided finally to stop second guessing myself and just dive right into the deep end.
The thing about weight, as you already know, is that it is terribly emotional. People skip out on needed doctor visits, especially after the holidays, because I *might* bring up their weight. I have worked hard trying to find compassionate ways to discuss weight with patients because I struggle with my own weight, but even that fails all too often. I feel like I should be better at this.
But I’m not.
As I was working my way through this yearly “open book test” thing for maintenance of my board certification last week, I realized that I was sorta hoping for my own eureka moment. Maybe there would be a holy grail somewhere in all of this research, the one thing that would help me know how to help patients…
The only thing they kept bringing up was motivational interviewing.
That is all we have to offer? That and surgery and meal replacement shakes and pharmaceuticals?
There was a provocative article from JAMA in 2013 that looked at mortality and BMI. Being overweight (a BMI of 25-30) was associated with a lower risk of mortality. That’s right. You are less likely to die if you are classified as overweight. Class I obesity (a BMI of 30-35) was not associated with increased mortality. In fact, only at a BMI of greater than 35, classified as Class II and III obesity, did increased mortality kick in. This makes me particularly angry every time I am forced to complete a biometric screening for someone’s employer that makes me downgrade their insurance rebate because their BMI is not under 25. We are emphasizing the wrong thing here and missing the whole point, aren’t we? Except that maybe it IS all part of the plan… make sure the work force dies quickly after retirement so they cannot draw a pension.
Perhaps I am being too cynical.
Maybe it is simply because sedentary people are not out there taking risks. You can’t get eaten by a mountain lion if you are not out there hiking, can you? No, sir!
Generally when I talk to patients I don’t reference BMI unless they ask me to do so. I also don’t talk about weight except to mention trends. For instance: “You lost some weight, way to go!” or “You gained some weight since your last visit, what are you doing differently?”
But what if even this is wrong?
What if everything I have been taught to do about weight is wrong? What if I should just take the focus off of weight and instead refocus attention on lifestyle exclusively?
No one has done that research, at least not that I am aware of.
Quite honestly, I am not sure that me talking about the numbers has really helped anyone over the years I have been practicing. You can be skinny and not really healthy at all. We all have *those* friends that make us shake our heads as we well up with intense jealousy. Why does SHE get to eat extra cheesy cheeseburgers at every meal, watch Netflix all day, and STILL wear a size two at age forty-two?!?!???! Believe me, I’d like to know as much as you would.
So I have been toying with the idea of going weightless for my 2016 New Years Resolution. I would plan to talk to patients more about lifestyle, but would not speak to weight or BMI at all unless specifically requested. I will be looking at the numbers but I won’t be talking about them. Instead, I will be asking about diet and exercise and sleep habits.
Truthfully, talking numbers is easier. Lifestyle is much, much harder to pin down for people. It will be a significant time investment. Maybe I will try it out for a few weeks and see how it goes…
What do YOU think? How would you feel about YOUR doctor doing this sort of thing?