Thursday, January 26, 2012

Are Weight Ignorant Allied Health Professionals the Exception or the Norm?

Probably the norm.

And frankly, I think it's unforgivable and that their ignorance belies the fact that weight bias is alive and well in allied health professions.

How is it possible that despite one third of the population having obesity that allied health professionals remain so clueless about how to even talk about weight, let alone how to manage weight related comorbidities, how to ensure they don't add to the problem with weight gaining medications, or how to assess whether that weight is truly problematic, or rather, a healthy variant of normal?

If 1 in 3 people had asthma, do you think allied health professionals would be beyond awesome at managing, counselling and dealing with it, along with recognizing when it's a big scary deal or rather a minor periodic inconvenience?

And it's only because we're talking about obesity that allied health professionals remain perfectly comfortable with their own ignorance. The fact that they can dismiss obesity as a moral failing of their patients - nothing to see here medically - helps to exonerate them mentally from having to actually help, counsel or treat the patient in front of them, or think about the problem's actual etiology. It also helps to exonerate them from actually taking it upon themselves to learn more - something they'd no doubt do were we talking about any other medical problem or condition that they might not know much about, but which affected over one third of their patient population.

Why the diatribe?

Today, my friend Travis Saunders, co-author of the blog Obesity Panacea, recounts his recent experience going to his doctor's. Brief background. Travis? He's stupid fit. He's the guy that makes you shake your head and wonder what kind of crazy crawled into him that makes him run, bike, and ski through sun, rain and snow, day in and day out. He's also an obesity researcher. A good one.

So what happened with Travis?

The nurse practitioner at his MD's office weighed him, saw that his BMI was nearing 25, and told him he should, "watch his weight" moving forward as he was nearing the "overweight" range.

You see Travis wasn't Travis to the nurse. He was BMI 24.5.

I suspect other folks visiting that nurse weren't Marge, or Bill or Peter, they were BMI 37, BMI 32, and BMI 29.

The fact that there was no thought on the part of the nurse? No consideration of Travis' lifestyle or actual health status? That's because I'd bet to her, weight's a very simple thing to deal with. It's not the complicated amalgam of hundreds of genetic, environmental, medical and behavioural contributors. It's not something that needs to be evaluated within the context of the whole. No. She's learned that when BMI is greater than 25, that's overweight, and when BMI's greater than 30, that's obesity. Easy peasy. No need for any further evaluation. Oh, and treatment? Easy, peasy too! Just, "watch your weight".

We all know how well that advice would work.

So is she a bad nurse? An exception? She's probably not either. You see as far as teaching goes, professional schools pretty much ignore obesity. That goes for medical schools, dietetic schools, nursing schools - etc.  Instead they teach body mass indices, waist circumferences and waist to hip ratios. They teach numbers. But unlike virtually everything else that's taught, when it comes to obesity, those numbers stay in vacuums, where individuals and thorough and thoughtful exploration of the issue isn't taught or recommended, because sadly, even in medicine, obesity is still considered to be just a reflection of your patients' deadly sins, which is probably why Travis' nurse never even thought to consider him as a person rather than a number.

To read Travis' thoughts and experiences, head over to his blog and have a peek.

To my readers out there who are professors in various allied health training programs - what are your schools teaching about obesity?  Is there a new tide turning?

I sure hope so.

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  1. Another great post challenging health pro's, and all of us, to open our eyes a little and get past the numbers.

    4 thoughts/ questions:

    Are professionals becoming embarrassed to address weight issues - "I have failed to keep my client in a healthful state through education, advice, and monitoring, and I'm embarrassed that it might imply that my approach wasn't correct"?

    Have nurses become so desensitized to addressing being overweight as a potential cause of health concern? It's prevalence, the casual reception of such information, rationalizations for it, that in the nurse's mind it's less of a headache to simply "colour by numbers", 24.8 = "watch your weight", 25.2 = "better lose a bit".

    Has weight become the new -ism that just isn't talked about lest someone be offended? Is it a new addition to workplace "Diversity" talks so that expressions like "the elephant in the room" are shunned for their size-related implications? Is this attitude trickling into doctor's offices?

    Does the BMI of the nurse or doctor affect the approach to diagnosis? If 1 in 3 are overweight, it's either the receptionist, the nurse or the doc! "How can I tell this person that they are overweight and should 'watch their weight' when I know I should too?"

    Thanks for your continuous flow of thoughts and info!

  2. I believe the tide is turning, at least in Saskatchewan anyway. For a number of reasons:

    Practitioners here are being trained in the Craving Change cognitive behavioral therapy program which helps address the root causes of emotional eating and cravings and helps clients improve their relationship with food. I have been facilitating this workshop for 4 years now and know there are at least 30 other AHP's in SK that are trained in this process.

    I also contract under the Aboriginal Diabetes Initiative here in SK (arm of Health Canada, on reserve First Nations) and in order to make a difference to people living with diabetes, we have been trained in the Discovering Diabetes Program. It's focus isn't traditional diabetes education, but to create curiosity within our clients and learn to ask more questions when it comes to diabetes management and care. Have the clients assess their own barriers to health and set their priorities. This curriculum is from Kris Swenson RN and Betty Brackenridge RD from Phoenix and is a diabetes self management program that's success is in the published research. Why I tell you all of this is because I shared Best Weights with them and they have been sharing the message of assessing all of the influences on weight and health not only with AHP's but most recently as this month, sharing the message with a physicians program that introduces the Discovering Diabetes program to the docs and links them up with the AHP's in the field who are providing that education. Kris and Betty are sharing the Best Weights message across every corner of SK and it is making a difference.

    My diabetes educator group (South SK Diabetes Educator Section of the CDA) brought Dr. Arya Sharma in to speak to 120+ diabetes educators AHP's last May and many of those SK educators left with another skill set, some of which had never considered before that weight loss was anything more than 'eat less, move more'.

    As a part of a Best Weights focus under the Aboriginal Diabetes in SK, we are bringing Dr. Sharma back to speak and are aiming for 350 this time. Not only AHP's but community health reps, health directors, home health aides, elders, mental health workers and anyone else who works on or off reserve who supports people in their health. Physical, mental, emotional and spiritual health.

    We are getting the message out here in Saskatchewan. Yet another reason (besides our strong economy and our beloved football team) as to why this is such a great province!

  3. I'm a clinical psychologist in a US medical school/medical center and you would be hard pressed to find any practitioner who knows anything about evidence-based weight management strategies at my institution. In the US, the Center for Medicaid and Medicare Services recently approved coverage for behavioral counseling for obesity but the hitch is only PCPs can bill for the service. PCPs have no training in any aspect of behavioral modification, nutrition, or exercise counseling. Not to mention we have a huge PCP shortage in the US. Behavioral counseling for obesity is my wheelhouse, I have published numerous papers on it, ran clinical trials for it, some might even consider me an expert, and I CANNOT be reimbursed to deliver this service where I work. So, not only do most practitioners not know how to do behavioral counseling for obesity, the ones who do are not even currently able to bill for it here in the US. Thanks for giving the issue some attention!

  4. Anonymous7:52 am

    This reminds me of a visit to my doctor for my annual check up. I eat very healthy ( I am an RD), I am very active and my BMI had always been stable and on the low end (~20). I love cardio activities, but wanted to gain more muscle through weight training which I had struggled with in the past, so I worked really hard with a great trainer over the course of the year to decrease my percent body fat and gain more muscle through weight training. The results meant that I was much fitter, my percent body fat decreased and my cardio performance increased…BUT, I had gained 5 pounds of lean muscle mass. Upon taking my weight, the nurse was very concerned when she told me that I gained 5 pounds since the previous year and that my BMI was rising. When I explained that the weight gain was a result of gaining muscle though training and that I had actually decreased my percent body fat and increased my fitness (including cardio performance), she stuck to her guns and suggested that I keep an eye on my weight gain. I was very concerned by her messaging and lack of understanding on the limitation of body weight and BMI (including one that still in the low end of the scale!). I agree, more training is needed!

  5. Anonymous8:07 am

    Wow - I went for my physical on Monday - I am 5 foot 2 and weigh 250lbs and no mention was made by anyone about my weight, my eating habits etc. The only question even relevant to my obesity was "so what is your activity level like", "I go to the gym 3 to 5 tomes per week" "Good for you!" this from my family doctor! If they were not in such short supply I'd find a new one!

    1. Anonymous, if a doctor treated me that way, I'd be thrilled!

  6. Anonymous9:05 am

    Do you think part of the problem is that no one really knows how to control weight/what causes obesity? Isn't that part of the reason why obesity levels are rising??

    How do you not gain weight over the decades? I'm a distance runner and make sure to get enough weight training in... But over the years i see my body changing even with a healthy lifestyle/diet even when I switch up routines.

    This is a silly question but it's an honest one, how on earth do celebrities stay so thin? The first thing that happens when someone gets famous is they shrink and most of them maintain that lower size. Seeing this makes the general population feel crappy... Like it IS possible to lose weight and keep it off but HOW? I'm more just voicing a thought rather than asking a direct question.

  7. Anonymous9:23 am

    I've had three really great encounters with doctors lately,and one reasonable one with a diabetes centre. All of them expressed their opinion that while personal responsibility had a small part to do with weight gain, overall willpower and a person's 'worth' had little. All of them are big on bariatric surgery.

    A cardiologist I was at yesterday said to me "you need to lose weight, but you won't. Your life is too 'big' with your kids and your job, and you should consider surgery. Not to say that you can't lose weight, but that doing so is a task beyond hard". It was sort of refreshing in having a doctor look at me and say "hey I get it, I know, I understand so lets move past it, and find some solutions to get healthy".

    I'm still not convinced on the surgery, but he made some great points (its not about cosmetics, its about health for the most part)

    Celebrities stay thin because they are being paid a lot of money to do so.(in my opinion). And I know that if I had the money to not work, and to be able to live a life of leisure, I'd be a lot more fit. When I was off on maternity leave, both times, I walked 5-10Km a day. Now I struggle with getting 2Km in. At least I do it, but finding the time for it while working and juggling kids, my mother, and the rest of my life, well its low on the priority list.

    Anyways, in my world, the medical profession has come a long way from the time when I was told to lose weight for my broken wrist, or that an anxiety incident was cause of my weight.

  8. You're absolutely right to characterize it as "weight-ignorant." People simply don't know what they don't know. Which is the worst-case scenario, because it means they don't know to refer to folks with true expertise.

    In our business, we work with a huge variety of health and wellness businesses and professionals - everything from personal training businesses with strong certifications and exercise science and nutrition degrees to licensed healthcare professionals - doctors, RDs, PTs, etc.

    I've shared perspectives like the EOSS approach and information on the etiology of overweight and obesity with many of them.

    And it's no understatement to say that their reaction has uniformly been "Wow, I had no idea." And quite a few of these are businesses that offer weight management programs and services!

    Just two quick examples - most of them (physicians included!) don't realize that weight gain is associated w/ certain psychiatric meds. Nor do they realize the issues that PCOS can present for weight loss, even when intake and activity levels are tightly regulated by the client.

  9. Thanks for the excellent tag-team post Yoni!

    Just one minor clarification - I don't have an MD, just an NP. It was an RN who gave me the comment about watching my weight, not the NP (it never came up again after the pre-physical height & weight screening, which may be because the NP and I had already discussed my diet and PA at a previous meeting, while I assume that her RN didn't know that info).


  10. I agree with you that we are clueless on how to handle these conversations. BUT it is not just Allied Health. It is ALL health care practitioners. I get referrals from all health care practitioners still re: weight loss. Whether that be nurse, social worker, doctor or nurse practitioner and even other dietitians. The problem lies in how deeply into our society, school system and health care system these risk stratification tools have been taken and twisted from their original purpose. We all need to re-learn what healthy living really is! And am thankful to read and share your insightful posts.

  11. Yoni,

    I have to share today's blog with all the health care providers I know!

    It's simple truth. and yet another perfect wake up call of yours.

    If health care providers in the Miami area:

    There is a free CME Course (8 credits) on Weight Loss Management Introduction in Medical Practices Sat Feb 4th With Dr Kasha, Md, Internal Medicine.

    Perfect first step... education!

    More info or register before noon tomorrow Friday the 27th of January 2012

  12. Anonymous6:32 pm

    My doctor telling me to lose weight was fine. I knew I had to lose weight, I'd packed on quite a bit.
    Having the same doctor decide that the cause of every single issue I ever came to see him about was due to weight: that was not helping. Feel short-breathed: lose weight. Shoulder bursitis: lose weight. Arthritis: lose weight. Difficulty in sustaining an erection (which is why this is anon :D ): lose weight.
    I definitely felt that he thought I didn't need any care other than to be told to lose weight.