Hello! Thank you for tuning into today's presentation on starting a journey to healthy weight, overcoming stigma and barriers. I'm Dr. Brady Addison, a clinical endocrinologist at South Texas Endocrinology and Metabolism Center in Corpus Christi, Texas. For disclosures, I do serve on the advisory board for Nova Nordis and I'm also a member of the Speaker's Bureau. Let's take a look at today's objectives. First, we want to look at starting a conversation about weight and health. How to avoid stigma and personal implicit weight biases to enhance our patient's engagement. How to address health at all sizes and different norms. We're going to look at how to prepare our staff and the office environment for a patient-centered obesity treatment. And then look at addressing barriers to access, such as coverage, finances, as well as the social determinants of health. And then lastly, we're going to talk about sharing decision-making when it comes to treatment options. Let's take a look at the definition. In 2014, ACE defined obesity as a chronic disease characterized by a pathophysiological process that resulted in increased adipose tissue mass, which can result in increased morbidity and mortality. In 2017, it was redefined as adiposity-based chronic disease, which was coined in an effort to identify it as a chronic disease rather than the stigma that has previously been associated with obesity. As we can see, ACE was an early adopter of the fact that obesity is a chronic disease. However, many others continue to struggle with this fact. Only 80% of health care providers believe that obesity is a chronic disease, and those patients who live with obesity, only 65%. Because of the lack of understanding of obesity as a chronic disease, many individuals will attempt multiple times to lose weight on their own. In fact, in a study completed by Kaplan and colleagues, we see that there's about seven serious weight loss attempts before an individual reaches out to the health care provider for any type of assistance. So exactly why is that? Well, one of the reasons is because of weight bias. We see here that weight bias is defined as a negative attitude towards and belief about others because of their weight. It ranks just below race, gender, and age as the fourth most common form of discrimination in the U.S. When we look at studies here completed by Steele and Bariatric Times, we see that in their lifetime, 5% of men and 10% of women with obesity report daily or lifetime discrimination due to their weight. This may be one of the reasons that they're hesitant to reach out to their health care providers in their attempts with their weight loss journey. Other barriers to patients reaching out for care may be implicit or explicit biases and even internalized weight biases. Let's take a look at what these three biases mean. An internalized weight biases is when a person applies a negative weight stereotype to themselves. Implicit weight biases is an unconscious bias towards a person who has obesity, a belief, or attitude outside of an individual's awareness or control. Whereas explicit weight biases is an awareness of the bias and intentional behavior negativity towards a person who has obesity. On the previous slide, we defined what an internal weight bias was. But exactly how does this affect our patient's weight loss journey? Well, there's two areas that we can see this play out, both psychological and in their behavior. From a psychological standpoint, when patients have internal weight biases, they have a reduced quality of life. They have more depression, anxiety, a lower self-esteem, and a poor body image. This can make it difficult when it comes to managing their weight because even when they lose weight, they always see themselves as being overweight. When it comes to behavior, it can cause them to engage in eating disorders, rejection of dietary advice, and avoidance of exercise. So it's important that we recognize these biases within our patients. As health care providers, how does our biases affect patient care? Well, after family members, we see that health care providers are the top source of obesity bias. Health care providers view patients with obesity as less adherence according to some studies. In fact, there's been other studies that have shown that health care providers tend to spend less time in the examination room with patients with obesity or doses overweight. And patients can feel the strain. And as a result, it creates this tension with the patient-physician relationship. We see that the patients are less likely to schedule preventative exams and more likely to counsel or not show to their appointments because of these perceived and felt biases. As we've seen with the pandemic, keeping routine care is important to prevent long-term complications. When it comes to obesity, we see that 68% of patients, women, would have been migrated to 55 delayed care due to biases, even when they had insurance coverage. This led to about a 60% increase in the risk of mortality associated with weight-based discrimination. What patients are seeing is that they're uncomfortable with their health care provider. They receive unsolicited advice and they feel a provided negative attitude when they're at their examinations. Now, let's transition to weight stigma. What is weight stigma? It's defined as thoughts or acts of discrimination towards individuals due to the weight and size. Disease stigma results from misconceptions and biases that exacerbate suffering on individuals with disease. The impact of stigma has long-term consequences. We see that patients become less confident in their ability to lose weight, which leads to more binge eating and less physical activity, and thus complications of both physical and emotional stress, such as increased risk of cardiovascular disease, diabetes and stroke, and increased risk of depression, suicide, and low self-esteem. So as clinicians, what can we do? In this next portion, we're going to look at how do we address patients with obesity. Megan and colleagues have developed a great approach titled ABCDEF, Approach to Open Dialogue with Patients Struggling with Obesity. A, ask for permission to discuss weight. B, be systematic. C, counseling and support. D, determine health status. E, escalate treatment when appropriate. And lastly, F, follow up regularly. We'll look at each individual area as we proceed through the slides. Let's take a look at the first area, ask for permission to discuss weight. We don't want to assume that just because a patient is overweight or has obesity that they're ready to discuss their weight. We don't want to feel like we're making a personal attack, so we want to make it an open discussion. We want to use terms as, can we discuss how your weight may be contributing to some of the symptoms you mentioned today? Would you be okay with discussing how your weight may be placing you at risk of other chronic diseases? We want to keep it very open so that the patient is comfortable with discussing when they're ready. And we want to be systematic in our approach. We want to have a game plan going in so that we ask the appropriate questions so we can pinpoint the patient's initiation of weight gain, find underlining triggers so that we can best serve our patients who are struggling with this disease state. A great approach is to remember your alphabets that was created by Hernandez and colleagues, O, P, Q, R, S, T. For instance, onset, precipitation, quality of life, remedy, setting, temporal pattern. If we use this, this helps us to really pinpoint the onset of disease, precipitating factors, how it has affected their quality of life, what they tried, the success and unsuccessful approaches they've seen, what it is like when they have their weight under control, and what they've seen along the way. This really helps to see what their struggles are, to see where we can best serve our patients. Weight charts are another great source. We can find this on our ACE website. It helps us to see the ups and downs of weight loss. We can see certain triggers, certain events in life that led to weight gain, what led to weight loss, and it makes it more visual. So let's take a look at counseling and support. How do we best be there to help our patients along their weight loss journey? So the first thing you want to do is remember to keep an open dialogue. We want to identify what the patient's goal may be. Often we hear that patients want to be the same size as they were in high school. Now we know that this is not a realistic goal, so we want to set realistic targets. We want to explore how their goals will be obtained and we want to set deadlines. As we've seen in other studies, and even in this one here, two-thirds of patients living with obesity are really wanting their health care providers to bring up their weight. There's an appropriate approach, one that shows a caring approach and not a blaming approach. One way to make the conversation more open and more approachable is to really shift the conversation from a personal attack on weight to one of the consequences of weight. When we start to talk about the chronic health problems that are a result of the overweight or obesity, patients are going to be more open, more willing to talk about it because they understand that their health is at risk because of their weight. Personally, when I discuss overweight or obesity with my patient, we like to discuss what their chronic health problems may be. Things that may be directly related to obesity, such as diabetes, PCOS. Arthritis is very common because patients are often complaining about joint pain, and this can be directly related to their weight. When they see that we're wanting to address those issues, wanting to improve those chronic health problems, and that by doing so, by losing weight, we can address these, patients are more open. They're ready. They're more motivated to get things done. However, as healthcare providers, we have to be realistic, and we have to have a holistic approach when it comes to our patients. We have to understand that as ready and willing as the patient may be, that there are some barriers, and social determinants of health will really help us to narrow down what these barriers may be. Let's review a few definitions. Health equality is everyone is given the same health intervention without consideration of underlying needs. Health disparities. Disparities are significant difference in health outcomes between populations. Health inequalities are unjust distribution of resources and power between populations, which manifests in disparities. And health equity is everyone has what they need to attain their highest level of health. So we often see that patients who struggle with obesity may not have the same access when it comes to care and affordability of anti-obesity medication. They may not have the same access when it comes to the ability to exercise in an environment that's safe. We see individuals who live in food deserts, which reduce their access to care. So these are some of the disparities and inequalities that we see that affect patients who struggle with obesity. These are things that we must keep in mind when we're discussing weight loss and interventions for our patients. This slide kind of reiterates what was said previously. There are a number of factors that can lead to the social determinants of health. We briefly discussed food, such as food deserts and patients limited access to good, healthy, quality food. We talked about community. And again, if living in an area that's dangerous, patients may not be able to engage in walking along the sidewalk for exercise. So again, this is just something that we need to keep in mind when we're approaching our patients about their ability to exercise or their food choices. As health care providers, we want to meet patients where they are. We want to cater to their needs. However, we must realize there will be limitations when it comes to addressing the social determinants of health. It really takes a team approach. We need to get health care environment involved. But we also need education, housing, transportation, agriculture and environmental societies to help us out as well. We want to be mindful of what our patients limitations are so that we know how best to serve them. So what other barriers are we facing when it comes to weight loss? We see that patients from lower socioeconomic status tend to have a lot of things that are juggling. They have a lack of time because they're usually working multiple jobs, a lack of access to resource. And also maybe child care or caring for elderly parents may also be limiting factors for their access and their ability to engage in physical activity. As far as bariatric surgery, there's fears and concerns about the treatment effects and the perception that surgery is too extreme or should be used as a last resort. Education is very key in addressing these issues. So as health care providers, what type of interventions can we implement to really help our patients? So when it comes to patients, we want to use interpersonal connections such as face to face encounters, family support. We want to really cater to what your cultural background may be. For instance, I practice in South Texas where there's a large Hispanic population. Most of the engagements are around food. Family members get together multiple times per week, but for sure once a week where they engage in food and they interact with one another. And this is just a part of their life. So there's often a sign that if you don't engage in the food, if you don't eat the food, it's a sign of disrespect. So really being able to sit down with these families to not take away what is part of their culture, but to learn to work with what is their culture. So that the patients still feel connected to their family, but they're able to make healthier choices while spending time with loved ones. As providers, it's important that we recognize these cultural barriers. And again, because if we tell a patient that, oh no, you shouldn't eat this or you shouldn't go there, then they feel like we're taking away their family, we're taking away their culture. And that's going to be a huge turnoff. So we really want to work within what they're doing and make the best choices. So in summary, the first step is to recognize that obesity is a chronic disease. This needs to be recognized on the physician provider level, as well as society and a patient level. Once we were able to do this, this will help us to get past the biases that have been created. Because we're seeing that these biases are led to delay or even prevention of proper addressing of obesity when it comes to patient care. By recognizing and addressing such biases, we're taking the first step towards providing quality care for our patients and helping them on their journey to weight loss. Thank you.

Elizabeth Bauer

obesity treatment

complications

diet

exercise

behavior modifications

multidisciplinary approach

obesity

weight bias

weight stigma

chronic disease

patient-centered approach