Sanjay Kalra ( Department of Endocrinology, Bharti Hospital, Karnal, India. )
Nitin Kapoor ( Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore (TN) -632004, India, and Non Communicable Disease Unit, Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia. )
Neeta Deshpande ( Department of Medicine, Belgaum Diabetes Centre & Childrens Diabetes Centre; Weight Watch Centre; MM Dental College, Belgaum; USM-KLE International Medical program, Belgaum, India. )
This communication describes the style and content of obesity-friendly language, so as to create a positive and welcoming environment for the obese individual accessing health care. Attention to matters of language and conversation style will ensure better a relationship between the patient and provider and facilitate optimal outcomes.
Keywords: Motivational interviewing, Overweight, Obese, Person-centred care.
Conversation binds humans together, and language is the building block of conversation. The art of motivational interviewing is a hallmark of a good physician's toolbox and is a major determinant of patient-provider relationship, as well as clinical outcomes. The importance of language has been highlighted in chronic disease management, especially in diabetes care.1 Salutogenic language usage is supported and encouraged in endocrine and metabolic care as well. The concept of salutogenic thought, words and actions has been proposed by experts.2 Similar movements have begun in the field of obesity care, but do not seem to have achieved "critical mass". The Awareness, Care, and Treatment In Obesity MaNagement" (ACTION) International Observation (ACTION-IO) study — study, conducted in 11 countries, and the ACTION study, carried out in the USA, highlight the importance of appropriate conversation in obesity management.3,4 The objective of country wide study done in USA was to investigate barriers to obesity management from the perspective of different stake holders including people with obesity (PwO) and health care professionals. In this ACTION study 71% of PwO reported that they have talked to their HCP regarding their body weight in the past 5 years. But only 38 % of them have discussed weight loss plan in past 6 months4. Compared with the US ACTION study, a smaller proportion of PwO in ACTION IO study had discussed their weight with an HCP in the past 5 years (US ACTION, 71%; ACTION-IO, 54%), though a larger number had a diagnosis of obesity (US ACTION, 55%; ACTION-IO, 67%).3,4
Although 67% of HCPs are comfortable discussing weight management with PwO, they face challenges in initiating the conversation. Of PwO who discuss regarding weight with HCP, only 24% reported that they have taken a follow up appointment for the same.4 This suggests that there is lack of communication between HCP and PwO on weight management. There is a need to use obesity friendly language while conversing with PwO to ensure appropriate dialogue.4 Obesity friendly language may help enhance the diagnosis as well as management of obesity.
The mnemonic WATER (Warm welcome; Ask and assess; Tell the truth; Express empathy; Reassurance and regular follow up), used for diabetes care, is equally applicable to obesity care (Figure).
The first conversation regarding weight is perhaps the most important. A Warm Welcome followed by questions aimed to Ask and Assess needs wishes and preferences are the first step in establishing a pleasant working relationship between patient and the health care provider. A comprehensive enquiry should be followed by a realistic appraisal of the current status, planned intervention, and expected outcomes of treatment (Tell the Truth), coupled with sensitivity and empathy (Expressive Empathy). Weight loss, and weight maintenance, are long-term projects which require Reassurance and Regular follow up.5
While WATER provider a macro view of watering the conversation around obesity, one must focus on the details of language as well. The patient expects his or her health care provider to be not only confident, and competent, but caring and concerned as well. An expectation of reciprocal respect and understanding underlies all person's contacts with the health care system. This must be fulfilled by the obesity care provider at not only the index, but later interactions, too.5
To Do and Not To Do
Box reminds us not to delay a conversation regarding weight, and not to distract the individual if he or she wishes to speak about weight. The physician must be sensitive to verbal and non-verbal cues which suggest that the patient wishes the topic of obesity to be broached. Repetitive movements over the abdomen, talk of weight related issues in family members or friends, discussion about dress sizes or frequent mention of favourite foods and beverages may suggest a need for weight loss intervention. Weight should not be trivialized, either: statements like "a little paunch is good for health" actually harm the cause of health.
At the same time, we must not demean the patient, or demonize his/her weight, by speaking in a judgmental way, or looking "down" upon his/her habits. In short, no action or word of ours should discourage the person seeking attention for obesity or obesity-related issues.6
An open approach characterized by a spirit of enquiry is the first step to active engagement. One should always request permission to discuss weight and proceed only after explicit approval is received. Empathy and understanding must be expressed, as opposes to sympathy and disinterest. Our attitude and talk should serve to encourage and energize the individual, rather than causing dejection and despair.
South Asian Peculiarity
It must be noted that all data from the West may not necessarily be extrapolatable to South Asia. South Asia cultures place a high premium on "chubby looks" and equate overweight with health. The relative age, gender and social status of the patient and the health care professional influence the choice of language, dialect, words and intonation to a great extent. The non-verbal language that accompanies a particular phrase or sentence modulates the meaning of spoken words, and the emotions associated with them.7 It becomes incumbent, therefore, to focus on obesity-friendly language while conversing with persons living with obesity.
A focus on obesity-friendly language is an important part of bariatric medicine. All health care professionals should ensure use of salutogenic, nonjudgmental and respectful language, while conversing with persons living with obesity.
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3. Caterson ID, Alfadda AA, Auerbach P, Coutinho W, Cuevas A, Dicker D, et al. Gaps to bridge: misalignment between perception, reality and actions in obesity. Diabetes Obes Metab. 2019; 21:1914-1924.
4. Kaplan LM, Golden A, Jinnett K, Kolotkin RL, Kyle TK, Look M, et al. Perceptions of Barriers to Effective Obesity Care: Results from the National ACTION Study. Obesity (Silver Spring). 2018; 26:61-69. 5. Kalra S, Kalra B, Sharma A, Sirka M. Motivational interviewing: The WATER approach. Endocr. J. 2010; 57: S391-S391.
6. Speer SA, McPhillips R. Initiating discussions about weight in a non-weight-specific setting: What can we learn about the interactional consequences of different communication practices from an examination of clinical consultations? Br J Health Psychol. 2018; 23:888-907.
7. Silverman J, Kinnersley P. Doctors' non-verbal behaviour in consultations: look at the patient before you look at the computer. Br J Gen Pract. 2010; 60:76-78.