Put the Patient First: Steps For Better Shared Decision-Making in Obesity Treatment

"Take two aspirin and call me in the morning" has been the long-running punchline for jokes about physicians. But the subtext of that approach is not particularly effective for successfully putting patients on a winning treatment pathway. That’s where shared decision-making (SDM) comes into play.

SDM was first mentioned in a 1982 federal report that described informed consent as "active, shared decision making," and that report "is widely considered to be the documentary origin of SDM in health care…This conception of SDM builds mainly on two ethical values manifest in the functions of informed consent: the patient’s self-determination and personal well-being," explained James F. Childress, PhD, and Marcia Day Childress, PhD, both of the University of Virginia in Charlottesville, in a 2020 AMA Journal of Ethics article.

Several previous BreakingMED Expert Analysis articles have explored how these medications can be best deployed to treat obesity as a chronic disease; how to jump start the conversation about weight loss using these medications in patients with obesity; and consideration of the conversation about weight loss in patients with T2D and obesity.

A key component of the SDM-talk launch: Check your biases before you enter the exam room.

"Obesity is a stigmatized condition. People with obesity are often incorrectly considered to lack willpower," explained Susan Z. Yanovski, MD, of the National Institute of Diabetes and Digestive and Kidney Diseases, and Jack Yanovski, MD, PhD, of the Eunice Kennedy Shriver National Institute of Child Health and Human Development, both in Bethesda, Maryland, in a recent JAMA Internal Medicine review. "Patients frequently internalize this bias believing that they are at fault for their inability to lose weight or maintain weight loss."

"We know that more than 40% of US adults have obesity, so virtually every primary care [PC] practice treats patients with obesity," Susan Yanovski said in a JAMA Podcast. "But until recently…PC physicians [PCPs] have lacked guidance on how to successful approaches to helping their patients." The Yanovskis, and others, have offered that guidance on strategies for SDM in treating patients with obesity with a "patient-centered approach."

The Weight of Words

If the patient is in the clinic for an acute problem, handle that right away, the Yanovskis advised. Then, if obesity is likely a contributing factor to that medical condition, and/or other disorders, seek permission to talk about their weight. Once all are on board, avoid the "shame game," emphasized Fatima Cody Stanford, MD, MPH, MPA MBA, of Harvard Medical School in Boston. "We don’t call it morbid cancer," she argued in a 2022 American Medical Association news article. "We don’t call it morbid Covid-19. So why call it morbid obesity?"

Next, ensure that the patient is communicating in their preferred "language," whether that’s a language besides, or in addition to, English; that their preferred pronouns are being used; and that they are in their comfort zone for medical terminology versus more common words.

For instance, in a 2021 Current Obesity Reports study, Sameera Auckburally, MBBS BSc (Hons) MSc, of Lancaster University in Lancaster, England, and co-authors, noted that the "terms ’weight’ and ’BMI’ were found to be the preferred and least offensive terms, whilst ’fatness’ was reported to be the least desirable word…Other terms such as ’obese,’ ’large size,’ and ’excess fat’ were also rated as undesirable, with ’morbidly obese,’ ’fat,’ and ’obese’ viewed as the most stigmatizing and blameful words." They reported that preferred language included terms such as "plus size," or "too much weight for his/her health."

The Yanovskis cautioned that healthcare providers "are not immune to weight bias. Patients report experiencing weight stigma from medical professionals, and this contributes to poor outcomes in multiple domains."

Next, choose and use an SDM tool. The Agency for Healthcare Research and Quality (AHRQ) advocates for the SHARE Approach, which "presents a five-step process for shared decision-making that includes exploring and comparing the benefits, harms, and risks of each option through meaningful dialogue about what matters most to the patient."

AHRQ also argued that SDM does not have to be a time-consuming process, pointing out "studies have found that clinicians can implement shared decision-making without increasing the length of the consultation time. One logistical tool they recommend is designating a space in the practice for department where the SDM discussion can take place.

"If your approach includes reviewing decision aids with patients or having them review such information on-site, you will need to create a comfortable space for them to use. You may also need to obtain equipment, such as a DVD player and screen, laptop computers, or tablets that patients can use to review aids that include audiovisual components," according to AHRQ.

Another option is SMART, according to which "goals should be specific, measurable, achievable, relevant, and time-bound," stated Nicole D. White, PharmD, of Creighton University School of Pharmacy and Health Professions in Omaha, Nebraska, and co-authors in a 2020 American Journal of Lifestyle Medicine article.

They added that the "SMART-EST goals are also evidence-based, strategic, and tailored to the patient…Once a patient demonstrates interest in engaging in a lifestyle modification to improve their health, providers can use the SMART-EST goal-setting process to assist the patient in generating a written action plan."

They offered an example of being specific: "It is easy to advise patients to ’work on their diet and exercise.’ But this counseling lacks important information like how much and what types of activity the patient should engage in, what constitutes a healthy diet, and which changes are most pertinent to the patient and their objectives," while achievable can mean "[s]etting an initial goal that is more realistic for the patient would be more appropriate. Goals should also consider the patient’s resources and stated barriers. A patient living paycheck to paycheck is not likely to engage a personal trainer, just as a patient with significant osteoarthritis of the knee is not likely to run stadium stairs for exercise."

Do Ask, Don’t Tell

There is the possibility that the patient will decline to discuss their weight. So, does that mean the SDM process is over before it’s even begun? Not necessarily, the experts said. The Yanovskis re-emphasized that if "patients indicate that they do not want to discuss their weight, focus on treating their current medical conditions and indicate availability to further discuss their weight if and when they wish to do so."

Of course, the fact that obesity and T2D are often co-conditions in a single patient will make that discussion a little easier. Then, the SDM can focus on choosing the right medication for them for T2D management with the added benefit of weight loss. Citing guidance from trusted sources—such as new recommendations from the American College of Physicians that call for the use of GLP-1 and SGLT2 inhibitors, but not dipeptidyl peptidase-4 (DPP4) inhibitors (metformin) to manage T2D—can be an educational tool.

The CDC has five tips for promoting medication management for patients with T2D through what it calls "collaborative drug therapy management (CDTM)," that includes asking patients about their medicines at each healthcare visit and referring patients to T2D self-management education and support services, such as those from the American Diabetes Association.

If the patient is contending with obesity only, the Obesity Medicine Association (OMA) offers the "2024 Obesity Algorithm," with "updated information on the mechanisms, evaluation, and treatment of obesity, including why obesity is a disease, how obesity causes the most common metabolic diseases encountered in clinical practice, and how to treat obesity to reduce disease risk."

In its sections on medication-based treatments for obesity, the OMA lists what it calls the "Top Weight Loss Medications," explaining that with "a wider selection of weight loss medications now available, patients may ask what the strongest or most effective weight loss prescription medication is. The answer is complicated. It is not always easy to determine which medication is right for a particular individual. The market is also rapidly changing, so it is important to keep pace with the available options and their pros and cons."

What are some other tactics for managing these reluctant patients? In a 2021 Advances in Therapy, Cathy Breen, RD, of St. Columcille’s Hospital in Dublin, and co-authors recommended using the "5 A’s model," which is used "to aid the delivery of meaningful weight management consultations, and has proven effective in improving physician-patient communication, patient motivation."

One of those "A’s" stands for "Ask Permission" to discuss weight management, bearing in mind that "individuals living with obesity experience body weight stigma in multiple aspects of their life, which can lead to feelings of guilt, shame and self-criticism. With this in mind, it is important to be aware of behaviors that could trigger such negative feelings and result in a reluctance to discuss weight." Providers should also be aware that part of SDM is acknowledging any previous attempts to lose weight, and exploring why they may not have been effective, they said.

As for the "A" for "Advise," Breen and co-authors cautioned that "reiterating the negative aspects of obesity without offering a realistic solution can contribute to feelings of helplessness and make [patients] despair of ever being able to make the necessary changes to manage weight and reduce their risk for multiple comorbidities."

Finally, Breen’s group emphasized that patients need to know that they’re not alone on the weight-loss journey. "Although PCPs lie at the center…efforts to manage overweight and obesity should be shared among all care providers to ensure the delivery of interventions that consider the environmental and psychosocial influences that impact obesity at a behavioral level, while addressing the physiological and psychological challenges of long-term weight management," they argued.

Jack Yanovski reported support from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Soleno Therapeutics/NICHD, Rhythm Pharmaceuticals/NICHD, Hikma Therapeutics, and Versanis Bio. Susan Yanovski reported no relationships relevant to the contents of this paper to disclose.

The study by Breen’s group was supported by Novo Nordisk and the International Medical Press. Breen reported relationships with, and/or support from, MSD, AstraZeneca, Sanofi-Aventis, Roche, and Eli Lily.

Aukburally reported no relationships relevant to the contents of this paper to disclose. A co-author reported support from National Institute for Health Research/Lancaster University, the British Heart Foundation/Lancaster University, and Novo Nordisk/Lancaster University.

Yanovski SZ, Yanovski JA "Approach to obesity treatment in primary care: A review" JAMA Intern Med 2024; DOI: 10.1001/jamainternmed.2023.8526.

O’Shea D, et al "Practical approaches to treating obesity: Patient and healthcare professional perspectives" Adv Ther 2021; 38: 4138-50; DOI: 10.1007/s12325-021-01748-0.

Aukburally S, et al "The use of effective language and communication in the management of obesity: The challenge for healthcare professionals" Curr Obes Rep 2021; 10: 274-81. DOI: 10.1007/s13679-021-00441-1.