You're Overweight There, I've Said It
Abstract & Commentary
By Allan J. Wilke, MD, MA, Chair, Department of Integrative Medicine, Ross University School of Medicine, Commonwealth of Dominica. Dr. Wilke reports no financial relationship to this field of study.
Synopsis: People who are told by their physicians that they are overweight or obese are more likely to identify themselves as such, more likely to want to lose weight, and more likely to try.
Source: Post RE, et al. The influence of physician acknowledgment of patients' weight status on patient perceptions of overweight and obesity in the United States. Arch Intern Med 2011;171:316-321.
Starting with the assumption that obese individuals' desire to lose weight is tied to their perception that they are overweight and that this places them at greater health risk, these researchers set out to answer two questions: Do obese and overweight people recognize their weight status; and do physicians' acknowledgement of that status influence their perceptions and behavior?
They analyzed data from the 2005-2008 National Health and Nutrition Examination Survey (NHANES), the ongoing national survey of the U.S. population. The inclusion criteria were: 20-64 years of age, having been told by a physician (or another health professional) that they were overweight, and having their height and weight measured and body mass index (BMI) calculated. A total of 7790 participants met the criteria. Of these, 5474 (70%) had a BMI ≥ 25, and of these, 2874 had a BMI ≥ 30. (These numbers represent the cutoffs for overweight and obesity, respectively.) The subjects were asked their heights and weights, whether they consider themselves overweight, what their desired weight was, and the number of their weight loss attempts.
The percentages of individuals with a BMI ≥ 25 were 29% for ages 20-34, 39% for 35-49, and 32% for 50-64. A similar pattern was observed for individuals with BMI ≥ 30. The subjects' self-reported heights and weights correlated well with the measured ones, although slightly less so for obese participants. Sixty-two percent of individuals with BMI ≥ 25 identified themselves as being overweight. For the purposes of being told by a health professional that they were overweight, the researchers did not distinguish between overweight and obesity. A total of 45.2% of subjects with BMI ≥ 25 had been told that they were overweight; 66.4% of those with a BMI ≥ 30 had been told. Using the group of subjects who had never been told they were overweight as the reference group, the researchers also calculated odds ratios (OR) for behaviors of those who had been told. Participants who had been told that they were overweight were more likely to identify themselves that way than participants who had not been told: 94.0% vs 63.1% for BMI ≥ 25 (OR 8.26), and 96.7% vs 81.4% for BMI ≥ 30 (OR 6.11). Similarly, participants who had been told they were overweight were more likely to want to lose weight than those who weren't told, 96.1% vs 73.7% for BMI ≥ 25 (OR, 7.58) and 97.4% vs 86.1% for BMI ≥ 30 (OR 4.84). They were also more likely to have attempted weight loss in the past 12 months, 64.5% vs 39.0% for BMI ≥ 25 (OR 2.51), and 64.9% vs 42.6% for BMI ≥ 30 (OR 2.24). These associations held when controlled for age, sex, race, education, income, marital status, whether patients had a routine source of health care, and number of physician visits in the last 12 months. Subjects who were older, female, had a routine place of healthcare, and had at least one physician visit in the previous 12 months were more likely to be told that they were overweight. Married participants or those living with a partner were less likely to be told. Non-Hispanic blacks were less likely to be told than non-Hispanic whites.
Commentary
We have reached and waddled past the tipping point in our nation's battle of the bulge. More than two-thirds of our citizenry are overweight or obese.1 Physicians and their weight-challenged patients are not on the same page when it comes to perceptions about weight status and obesity's inherent dangers. Physicians consistently place their patients in higher weight categories than the patients place themselves and assign considerably more risk to their health. Patients are abundantly optimistic about their ability and motivation to lose weight and the amount they can lose.2 I suppose we could be wrong, but more likely, we're not, having observed the great difficulty most people have trying to lose weight.
This study has good news and bad. The good news is that patients are very honest when reporting their heights and weights and they are more likely to consider themselves to be overweight, to want to lose weight, and to try to lose weight if they are told by a physician that they are overweight. The bad news is that more than a third of individuals who are overweight do not recognize their weight status, and more than half had never been told by their physicians that they were overweight. I do not like to scold, but in what other epidemic is a physician response rate less than 50% acceptable? Of course, since this is a study that depends on patients' self report, we really don't know what their physicians may or may not have said. However, my anecdotal observations of my medical students' estimation of weight on examination of standardized patients leads me to believe that they do not recognize overweight or obesity when they see it. Perhaps it is generational, and "overweight" is the new "normal." Whatever the reason, we just do not do well in this area.3 More bad news that group of subjects aged 35-49 that comprised the biggest chunk of overweight and obese patients? They are going to be around for a while. The tsunami is approaching.
Wanting to lose weight is not the same thing as losing it, but patients must start somewhere. In an accompanying commentary, Dr. Baron ponders whether patients may be insulted if we confront them with their obesity.4 It reminds me of the discomfort we felt a generation ago, confronting patients who smoked cigarettes with their habit. (It also spawned a wonderfully weird Steve Martin routine: "Do you mind if I smoke? Uh, no, do you mind if I fart?")5 There are other uncomfortable parallels. Remember when doctors recommended certain brands of cigarettes? Remember how difficult it was for doctors who smoked to advise their patients to quit? Will doctors who are overweight be able to effectively confront their overweight patients?
Words are powerful. Dr. Baron reminds us that there is support in the literature for advising physicians to tell their patients to quit smoking.6 He recommends modifying the "5 As" approach to smoking cessation and apply it here: Assess obesity risk; Ask about readiness to lose weight; Advise in designing a weight-control program; Assist in establishing appropriate intervention; and Arrange for follow-up.7 For physicians who are squeamish about bringing up the topic, he recommends the following: "I am concerned about your weight. Today's measurement places you in the overweight (or obese) category according to our medical definitions." To that I would add, "What would you like to do about that?"
References
1. Flegal KM, et al. Prevalence and trends in obesity among US adults, 1999-2008. JAMA 2010;303:235-241.
2. Befort CA, et al. Weight-related perceptions among patients and physicians: How well do physicians judge patients' motivation to lose weight? J Gen Intern Med 2006;21:1086-1090.
3. Melamed OC, et al. Suboptimal identification of obesity by family physicians. Am J Manag Care 2009;15:619-624.
4. Baron RB. Telling patients they are overweight or obese: An insult or an effective intervention? Arch Intern Med 2011;171:321-322.
5. Martin S. Born Standing Up: A Comic's Life. New York, NY: Scribner;2007:116. ISBN 9781416553649.
6. Stead LF, et al. Physician advice for smoking cessation. Cochrane Database Syst Rev 2008;(2):CD000165.
7. Fiore MC. US public health service clinical practice guideline: Treating tobacco use and dependence. Respir Care 2000;45:1200-1262.
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