Given my history of Anorexia Nervosa, and all of the work I’ve done to have a healthy relationship with my body, I pay close attention to how we are talking about weight with patients. I think everyone is aware that our country has ever-rising rates of obesity, and with that comes type 2 diabetes, metabolic syndrome, and a host of other health problems. But we are also in the midst of a mental health crisis. Things like eating disorders, anxiety and depression are finally getting some much deserved attention. There seem to be two completely separate camps when it comes to addressing weight in the media. There are plenty of people promoting various diet and exercise programs on one end. Then there is the Health at Every Size Movement which acknowledges that diets don’t work and weight doesn’t give a complete picture of health.
I asked on Instagram stories and almost unanimously you all said you wanted a post on how we deal with weight in clinic. Inpatient care is focused more on acute disease processes, so weight management is mostly done in an outpatient setting. I’ve been pleasantly surprised with what I’ve observed while working in various outpatient clinics as a student. Obviously it differs for each provider and for each patient situation. The following is just a general overview.
Weight & BMI
Our electronic medical records do calculate BMI for us. We often refer to it as a general gauge, but gratefully no one I’ve worked with has taken it as Gospel. So far, providers have been aware that BMI can be affected by things like muscle mass. Everyone seems to know that BMI isn’t the best indicator of health.
Usually weight isn’t addressed unless it is fairly drastically high or low, or unless there are health issues it’s affecting. More often than not, our overweight patients are also struggling with diabetes, hypertension, sleep apnea, joint pain, etc. We usually address the role weight plays in those conditions, and how some weight loss can help. If a patient is healthy but has a weight outside the “healthy” range, it often isn’t discussed much at all. A, “Just be aware and keep an eye on it,” approach is common.
For those patients whose health could benefit from weight loss, there is a brief discussion of healthy habits. Unfortunately appointment slots don’t allow for any in depth conversation. I wish! But most providers will suggest lots of fruits and veggies, less fast food and processed foods like chips, and less sugary drinks. Specifically for patients with diabetes, many will mention that lower carb diets can be helpful. We are lucky that at my current clinic we have access to a dietician and can refer patients for a nutrition consult. I wish all patients had that access!
As for exercise, providers often cite the current CDC guidelines. Often we suggest something as simple as walking more. I like to make sure patients know that exercise doesn’t have to mean running or lifting weights. It can be whatever activity they enjoy and gets them moving.
With Kids and Teenagers
I have found that providers are much more careful about eating disorder and body image with kids than with adults. I’m glad we are recognizing that a lot of diet and weight loss talk can be damaging to young people, but it can be for adults too!!
Parents are usually involved is the discussion about kids and teenagers. We sometimes teach them about the risks of carrying too much weight, especially as we get older. But generally, conversations about weight with kids focus on healthy habits. Often parents need a little nudge to get their kids to eat a more nutritious diet. We talk about eating fruits and veggies, limiting sugary drinks, and making sure kids get plenty of exercise and play time. We do a lot of education about sugary drinks like gatorade, juice, and frappuccinos!
It’s nice to have some time away from parents, such as during the teenager’s HEADSS exam, to talk one on one. I like to always ask patients how they feel about their weight, and how they feel when we talk about their weight. I promote body positivity and self esteem, and encourage telling their parents if negative weight talk is bothering them. While I do sometimes discuss lifestyle changes and getting to a healthier weight, I want them to do so out of a place of self care and not self-hatred or fear or shame.
There are lots of things I wish were different about how medicine is practiced today. I have dreams of a more “health coaching” approach to patient care. I’d love time for long lifestyle discussions and delving into how mindset and mental health is affecting how we treat ourselves. Hopefully, providers get more education on eating disorders and learn the best ways to promote healthy habits without causing psychological damage. There is work to do, certainly, but I think providers are doing a pretty good job right now.