Primary care physicians (PCPs), is managing obesity too overwhelming? Would practical, step-by-step guidelines, including patient input throughout, be welcome in your clinic?

You now have a chance to lay out that welcome mat.

This summer, researchers from Spain published a roadmap for personalized obesity management that shows providers and patients how to devise a plan that will hopefully meet their goals. The authors identified numerous elements that precluded patients with obesity from achieving maximum benefit from the time spent with their physicians, including lack of shared understanding regarding goals, poor communication, and stigma.

Based on Obesity Canada’s 5As of Obesity Management — ask, assess, advise, agree, and assist — the roadmap adds a sixth A: arrange, that is, should a specialist be needed for a follow-up.

Medscape turned to Jay Shubrook, DO, professor at Touro University California College of Osteopathic Medicine in Vallejo, California, director of the Diabetes Institute, and founding chair of the executive board of the American College of Diabetology, for his opinion on this new obesity management model.

Overall, is the model applicable?

I think it is great. It is best practice if it is done well, in a single setting or longitudinally, it gives the best chance for individuals to achieve goals and challenges. The devil’s in the details.

The Canadian 5As management plan identified 43 topics for the patient and physician to discuss at their first session. Is that a lot?

Yes. [But] the challenge is, like other chronic conditions that come with stigma, there’s much to unpack. If I am seeing a new patient, I don’t know if the patient wants to discuss their weight or spend 3 hours doing so. That is why PCPs are so well suited for this because they know a lot about your patients. Nuancing is great, but application with a wide variety of patients is the tricky part.

Does stigma still exist?

100%. Even with more obesity treatments, the world of body shaming is as strong as ever. It starts earlier than any of us are aware; that is why these models help so you can unpack some of that. If I don’t know what someone’s challenges or triggers are, I might not give helpful advice or something worse. With longitudinal care, you can understand their context for their discussion.

What differentiates obesity as a complex, chronic disease from other, complex, chronic diseases?

The blame. People don’t blame those with most other chronic diseases for having them. Diabetes is one; people only recognize the weight factor, not any others. Others are metabolic equivalents of task. Even with polyendocrine metabolic ovarian syndrome, people make unfounded or incomplete judgments. And patients feel them. Our environments contribute to this. Resizing clothing, for example, is enabling. We don’t create the space to talk about challenges and get medical help.

Please discuss the importance of patient input to their treatment.

Some patients will agree to do something, but they may be just deferring to a physician. The beauty in this model is laying the groundwork of mutual respect first, which creates opportunity for more meaningful agreement.

What changes might you make to this model?

I think every step should have a reset. So if they say yes or no to something, you can assess. Giving the patient the option to stop and start again later, takes it one step further, so you control the progression’s cadence. A patient might want time to think about it and then return in a couple of weeks.

Are physicians impatient to go from A to B to C to D without a reset?

That is probably true, PCPs are goal-oriented, they think “My goal is to get treatment moving.” Being able to reset or loop back to stop at any time until the patient is willing to engage again is important. If the patient doesn’t appear committed, it could be an issue such as a life circumstance in which they lack the necessary support to maintain the plan.

In the model, physicians are advised that the first conversation with the patient with obesity should “not be simplistic.” How would you interpret that in terms of recommendations?

That says to me, “Don’t say, ‘eat less, do more.’” Every person is different. That phrase doesn’t make sense; it isn’t measurable or individualized, and it could be harmful to the end goal. If I do one more step, is that doing more? Or take one less bite, is that doing less? Let’s lay out the plan in complete detail — the goal, timelines, and so on — and then I can give you the best advice on how that is achievable.

It takes years to get that heavy, yes?

It depends; many ways exist to get there. Someone could have hypothyroidism and gain 30 pounds in 2 months. So I ask, tell me about your weight history — from childhood. Birth weight? Did you reach normal milestones? When did your weight trajectory change? I ask what has worked, not what they’ve tried. People are often successful but either couldn’t sustain the weight loss or the goal was unrealistic. So maybe that successful try is part of the future plan.

In discussing obesity and its implications, how should physicians balance reality with scare tactics?

To me, scare tactics work only once. If you say you are going to die if you don’t do this, and you don’t die, it will never work again. So if you are going to have a longitudinal relationship with someone, you will have to understand the patient’s why in mapping out their treatment plan. Maybe the why is how they look or how they feel. Understanding the why lets us give something that is relevant to them. Let’s achieve the first healthy set point, and that gives you a bunch of little victories as opposed to thinking, “if I don’t lose 70 pounds by next week, I am a failure.”

No disclosures were reported.