Published in the July 2010 issue of Today’s Hospitalist
FOR A CONDITION THAT EXACTS such a terrible toll, obesity is surprisingly under-recognized by inpatient physicians. And even when hospitalists do identify a patient as obese, less than one in 10 bothers to schedule any intervention to help patients lose weight.
Those are the results of research headed up by hospitalist and researcher Erica Howe, MD. In a 2009 survey of hospitalists at Baltimore’s Johns Hopkins Bayview Medical Center where she works, Dr. Howe found that hospitalists correctly assessed inpatients’ weight only half the time (48%). When they erred, hospitalists under-estimated patients’ weight twice as often as they over-estimated it.
And in a study published last month in the Southern Medical Journal, Dr. Howe looked at how infrequently hospitalists intervene when treating obese patients, and why. A chart review found that while 49% of patients admitted were obese, doctors documented obesity in only 19% of admissions. Only 7% of admission notes included any care plan targeting obesity, such as ordering a nutrition consult or restricted diet, or offering weight-loss counseling. And even when plans were made, none was carried out.
While physicians regularly counsel patients to quit smoking, Dr. Howe’s team found that a full two-thirds of hospitalists felt that obesity is not an acute issue they need to address. And one-third was convinced any counseling given to obese patients would fall on deaf ears.
Dr. Howe spoke with Today’s Hospitalist about why hospitalists continue to avoid what she calls a great “teachable moment” for obese inpatients.
Q: Why are physicians so reluctant to discuss obesity with patients?
Many hospitalists have approached their practice as acute medicine only and think obesity is a problem for outpatient providers. But we always address chronic conditions like diabetes, so I think the real reason is that we’re not educated about obesity and on how to have that kind of patient conversation.
Q: Is that discussion much harder to have than one on, say, quitting excessive drinking?
Patients have so much self-image wrapped up in obesity, and providers know that. With other chronic conditions, you can talk more about the disease. But obesity is more obviously related to certain behaviors, and we have a tendency to worry that patients will feel ashamed or blamed for their disease.
But providers have to get past that and say, “We need to talk about this, we need to educate you on how to improve your diet and exercise regimen.” We have uncomfortable conversations all the time about how patients’ lifestyles affect their bodies. This is simply one more conversation we need to get used to having.
Q: Have you begun discussing obesity with patients?
I have, and it’s not an easy conversation to have. But I’ve been surprised at how much patients want to talk about it. They really want education, they really want an intervention, and they’re very forthcoming about what they’ve tried. We need to realize that we’re the ones in the conversation feeling uncomfortable, much more than patients.
Q: One of your studies found that hospitalists are better at documenting obesity and ordering interventions for younger patients than for older ones. Why is that?
I think we see younger patients as more able to change. And older patients may have comorbidities “like osteoarthritis ” that might prevent them from immediately doing interventions we’d suggest.
But we’re again letting our own biases keep us from helping every patient. We need to provide everyone with the same information, education and tools.
Q: As far as inpatient interventions, which are the most successful?
We don’t know because these interventions haven’t been studied. But in the outpatient setting, a multidisciplinary approach has been most effective: addressing behavior, motivation, nutrition, exercise, and family and social support.
Q: Should hospitalists talk about obesity at every visit or wait until discharge?
There aren’t data on this so far, but I think the optimal approach is to address obesity from admission on. As soon as patients arrive on the floor, you should begin the discussion. “You came in with chest pain. Do you know how your obesity relates to that?”
Perhaps you survey them to find out where they are in a motivational spectrum, then order a nutrition consult and continue the conversation daily. Specific points to cover could include how obesity affects their health and what tools they can use, like keeping daily food logs and wearing a pedometer.
Carry that discussion through to discharge and make sure they have good follow-up. When we initiate the discussion, we make it much easier for the outpatient physician to refer to the discharge summary and say, “I notice the hospitalist discussed weight management. What do you think?”
Q: One reason hospitalists gave for not addressing obesity was lack of time. Is that really an issue?
If you start the conversation on day 1, you’ve already had multiple conversations. You then spend five more minutes at discharge recapping the plan you’ve discussed.
It’s just like the tobacco cessation interventions we all do, which don’t require a 20-minute conversation. It’s giving patients information about tools that have been successful, like the importance of eating breakfast and the need for exercising 30 minutes a day.
Q: Of all the reasons that hospitalists give for not starting this discussion, which is the most frustrating for you?
The idea that we as physicians aren’t going to be successful intervening. As hospitalists, we see patients for only a short amount of time, so we don’t see how we may make a difference. That makes us wonder if we should bother to spend the time to intervene.
Q: Smoking-cessation counseling is now a core measure. Should obesity counseling be one too?
I think it absolutely should be, but we’re a long way off.
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
Why don’t hospitalists address obesity?
SURVEYING HOSPITALISTS at Baltimore’s Johns Hopkins Bayview Medical Center, Erica Howe, MD, asked why only a small minority of them document when inpatients are obese or come up with a weight-loss care plan. Here were the reasons hospitalists gave:
- Obesity isn’t an acute issue: 67%
- I don’t have time: 63%
- I don’t feel skilled in obesity counseling or treatment: 37%
- Any efforts to help patients will be unsuccessful: 33%
- I didn’t realize so many of my patients were obese: 20%
- I won’t be reimbursed for addressing obesity: 13%
Source: Southern Medical Journal