1. Obesity Sensitivity Training as a Tool for Improving Patient Education Pam Webber and Mary Kinnebrew Fort Collins Family Medicine Residency Poudre Valley Health System Fort Collins, Colorado

2. Overview Weightism Weightism Background on Federal Grant Background on Federal Grant Understanding complexity of problem Understanding complexity of problem Magnitude of problem Magnitude of problem Societal and cultural factors Societal and cultural factors Understanding the patient perspective Understanding the patient perspective Opportunities to practice and evaluate skills Opportunities to practice and evaluate skills

3. Weight Bias Health professionals specializing in obesity were given an association test at a national obesity meeting Pro-thin, anti-fat bias Pro-thin, anti-fat bias Endorsed implicit stereotypes of lazy, stupid and worthless Endorsed implicit stereotypes of lazy, stupid and worthless Schwartz, Chambliss, Brownell, Blair and Billington, (2002). Weight bias among health professionals specializing in obesity. Obesity Research, 11,9 1033-1039.

4. Tools for assessment http//implicit.harvard.edu/implicit/ http//implicit.harvard.edu/implicit/ Scales Scales BAOP Beliefs About Obese Persons BAOP Beliefs About Obese Persons Attitudes Towards Obese Persons Attitudes Towards Obese Persons

5. Why care about sensitivity? Stewart (1995) in the Canadian Medical Association Journal reviewed randomized controlled trials on patient physician education. Stewart (1995) in the Canadian Medical Association Journal reviewed randomized controlled trials on patient physician education. Correlation between effective physician- patient communication and improved patient health outcomes Correlation between effective physician- patient communication and improved patient health outcomes Effective communication included – showing support and empathy, asking about feelings, conveying clear information with emotional support Effective communication included – showing support and empathy, asking about feelings, conveying clear information with emotional support

6. Why Care? Beach et al (2005) Annals of Family Medicine used the Commonwealth 2001 Health Care Quality Survey of 6,722 adults Beach et al (2005) Annals of Family Medicine used the Commonwealth 2001 Health Care Quality Survey of 6,722 adults Correlated involvement in decisions and treatment with dignity with patient satisfaction, adherence and receipt of optimal preventive care. Correlated involvement in decisions and treatment with dignity with patient satisfaction, adherence and receipt of optimal preventive care. Being treated with dignity and being involved in decisions were independently associated with positive outcomes Being treated with dignity and being involved in decisions were independently associated with positive outcomes

7. Federal Training Grant Diversity Curriculum using the principle of cultural humility (Tervalon and Murray-Garcia, 1998, Journal of Health Care for the Poor and Underserved, 9(2),117-123. Residents more likely to involve patients in agenda setting More likely to solicit patient perceptions related to illness More likely to solicit patient perceptions related to illness More likely to involve patients in decision making More likely to involve patients in decision making Residents identified challenges with obese and chronic pain patients Residents identified challenges with obese and chronic pain patients

8. Prevalence of Overweight and Obesity Among US Adults, Age 20-74 Years* Overweight or obese BMI >25.0 Overweight BMI 25.0-29.9 Obese BMI ≥30.0 Percent BMI = body mass index. *Age-adjusted by the direct method to the year 2000 U.S. Bureau of the Census estimates using the age groups 20-34, 35-44, 45-54, 55-64, and 65-74 years. NHANES II 1976-80 (n=11207) NHANES III 1988-94 (n=14468) NHANES 1999 (n=1446) NHANES III 1999-2000 (n=4115) Projected 2008

9. Obesity Trends* Among U.S. Adults: BRFSS, 1988 Mokdad A.H., CDC (*BMI > 30, or ~ 30 lbs overweight for 5’4” woman)

10. Obesity Trends* Among U.S. Adults: BRFSS, 1994 Mokdad A H, et al. J Am Med Assoc 1999; 282:16 (*BMI > 30, or ~ 30 lbs overweight for 5’4” woman)

11. Obesity Trends Among* U.S. Adults: BRFSS, 2000 Mokdad A H, et al. J Am Med Assoc 2001; 286:10 (*BMI > 30, or ~ 30 lbs overweight for 5’4” woman)

12. Biology Behavior Environment Obesity

13. Weight Management A Complex Problem Genetic Genetic Metabolic Metabolic Physiologic Physiologic Cultural Cultural Social Social Behavioral Behavioral

14. Long-term Behavioral Treatment of Obesity StudyMaximum LossLoss at Last Visit Perri14% at Week 2013% at Week 72 Viegener 9% at Week 26 9% at Week 52 Wadden14% at Week 5212% at Week 78 Wing13% at Week 2610% at Week 52 Wadden, Sanwer, In: Goldstein (ed.) The Management of Eating Disorders, Humana Press, 1996

15. Other weight loss statistics In a study of 107,804 dieters, it was concluded that 80% of people who start a diet pick one that is virtually guaranteed to fail. JAMA 1999; 282: 1353-1358. In a study of 107,804 dieters, it was concluded that 80% of people who start a diet pick one that is virtually guaranteed to fail. JAMA 1999; 282: 1353-1358. Some authorities predict that 95% of people who are able to lose weight, regain that weight within five years Some authorities predict that 95% of people who are able to lose weight, regain that weight within five years

16. “You can never be too rich or too thin.” The Duchess of Windsor

17. Thin is glamorous

19. BAGEL 20 Years Ago Today 140 calories 3-inch diameter How many calories are in this bagel?

20. 140 calories 3-inch diameter Calorie Difference: 210 calories 350 calories 6-inch diameter BAGEL 20 Years Ago Today

21. How long will you have to rake leaves in order to burn the extra 210 calories?* *Based on 130-pound person Maintaining a Healthy Weight is a Balancing Act Calories In = Calories Out

22. If you rake the leaves for 50 minutes you will burn the extra 210 calories.* *Based on 130-pound person Calories In = Calories Out

23. COFFEE COFFEE 20 Years Ago Coffee (with whole milk and sugar) Today Mocha Coffee (with steamed whole milk and mocha syrup) 45 calories 8 ounces How many calories are in today's coffee?

24. COFFEE COFFEE 20 Years Ago Coffee (with whole milk and sugar) Today Mocha Coffee (with steamed whole milk and mocha syrup) 45 calories 8 ounces 350 calories 16 ounces Calorie Difference: 305 calories

25. How long will you have to walk in order to burn those extra 305 calories?* *Based on 130-pound person Maintaining a Healthy Weight is a Balancing Act Calories In = Calories Out

26. If you walk 1 hour and 20 minutes, you will burn approximately 305 calories.* *Based on 130-pound person Calories In = Calories Out

27. MUFFIN 20 Years AgoToday 210 calories 1.5 ounces How many calories are in today’s muffin?

28. 20 Years AgoToday Calorie Difference: 290 calories 500 calories 4 ounces MUFFIN 210 calories 1.5 ounces

29. How long will you have to vacuum in order to burn those extra 290 calories?* *Based on 130-pound person Maintaining a Healthy Weight is a Balancing Act Calories In = Calories Out

30. If you vacuum for 1 hour and 30 minutes you will burn approximately 290 calories.* *Based on 130-pound person Calories In = Calories Out

31. THE GAP American Healthy CultureLifestyle It’s getting wider wider

32. Understanding the patient’s perspective Discussion of supportive language Discussion of supportive language Empathy Suits Empathy Suits Visit with physician while wearing suit Visit with physician while wearing suit Videotape Videotape Different patient perspectives Different patient perspectives

33. Supportive Language OLD Overweight, obese WillpowerPreachCompliance Should, must Limit, restrict PrescribeApprovalExpectationsGood/BadDiet Exercise regimen Ideal Weight from Centers for Obesity Research and Education (CORE) NEW Person/patient of size CommitmentEnableExplorationConsider Choose, experience NegotiateSelf-esteemDiscoveries What works for you Eating Style Activity Style/Physical activity Healthy weight

34. Practice and evaluation Standardized patient encounters Standardized patient encounters Shadowing in clinic Shadowing in clinic Precepting in clinic Precepting in clinic Small group discussion Small group discussion

35. “Rather than feel anger or revulsion toward this person, my first obligation, especially if I am in the helping professions is to understand him or her: to gain insight into what it is like to be him or her; to imagine and to interpret the world from his or her perspective of experience…” John Banja, PhD Obesity, Responsibility, and Empathy, The Case Manager, Nov/Dec 2004

36. Contact Information Pam Webber Fort Collins Family Medicine Residency 1025 Pennock Place Fort Collins, Colorado 80524 webbpa@pvhs.org 485-8800