The hardest step - approaching healthcare professionals to ask for help with obesity By Stephanie deGiorgio

Writing this has been something I have been a little nervous about doing. As a GP I intensely dislike reading articles about how bad we are at doing certain things and so I didn’t want to just write one of those. As someone who has been significantly overweight and who talks to others in that position, I am acutely aware that a large part of the health profession and in fact the system as a whole is letting down a large number of those who approach it for help with the chronic disease that is obesity.

I should start by explaining that I had a gastric sleeve operation in April 2017. It has been life changing for me and I bring that experience and those of being an overweight patient as well as a GP looking after patients with weight problems into this blog. Like many people I had tried for years to lose weight and had been successful many times. But also like mamy people, in fact 95% of those who are obese and lose weight, it soul-destroyingly all went back on again with extra.

Like so many people who are affected by obesity, I had also been doctor avoiding. I had been getting horrible upper abdominal pains for a couple of years which I put down to eating too much and berated myself every time for being fat and doing this to myself. It was only after a really severe episode on a train that I realised it was caused by gallstones….and me, a doctor. My personal experiences of medical fat-shaming and my own negative inner monologue had caused me to have 2 years of utterly unnecessary pain. My gallstones, however, proved to be a blessing in disguise, as the prospect of having abdominal surgery made me realise that I could then perhaps consider having two ops at the same time; bariatric surgery and my gallbladder removed. Until then I had, wrongly, never considered bariatric surgery “worthy” of a general anaesthetic. I was recommended a wonderful and talented surgeon and his team and both procedures went ahead.

Since I have been open about my surgery and my involvement with #obsmuk on twitter, I have had so many people tell me about their own negative experiences of going to see their doctor about being overweight. Others have told me about their weight being brought up at every opportunity to the detriment of the problem that they have actually gone in with. Others have had serious symptoms put down to their weight when actually something else was wrong with them. These stories are so depressingly common that they simply cannot be dismissed as the odd bad experience and it stops people from accessing healthcare for any problem not just their weight.

This seems like a sad state of affairs and research evidence backs it up. Patients with obesity are less likely to visit their GP; women affected by obesity are less likely to have smear tests. GPs spend less time with overweight patients and are more likely to wrongly put symptoms down to obesity. The environment within a healthcare setting may be difficult for those who are obese to navigate, chairs with arms, examination couches that can’t take their weight or someone making a big deal of having to change to a bigger blood pressure cuff. This isn’t confined to primary care by any means, it is systemic throughout the whole health system, even in terms of limiting access to bariatric services.

Interspersed with these upsetting stories, I also hear of patients who have seen their GP and have had a great outcome. They have been listened to, they have had a useful, non-judgemental discussion and they have come away feeling that their problem has been understood and helpful plans have been made. For some, this may be after years of not daring to go back after a bad encounter and it may well be a life-changing moment. It isn’t going to make them instantly able to lose weight and keep it off, but it has been the start of a dialogue that makes that much more likely to happen. It is infinitely more satisfying for the doctor and patient.

Healthcare professionals, quite rightly, feel it is important to discuss obesity as a cause of other chronic disease or conditions. I don’t believe it is a healthy state of being, but I do very readily understand how accepting one’s obese body can bring an end to the negative inner monologue compared with the constant battle against our bodies caused by the physiological adaptations facilitating weight regain. The mental anguish and chronic stress caused by that must be as, if not more harmful, than the obesity itself.

So how do we ensure that these conversations can be done in a way that leaves the patient feeling empowered having received realistic and achievable advice rather than shamed, upset and vowing never to return for any medical problem? And how should patients who

are suffering from obesity approach a health care provider in a way that is likely to get a helpful response, especially if they have had previous bad experiences?

There is a whole other article waiting to be written for health care professionals about successful consulting on obesity, this one if for those who have the condition and I am going to offer some tips on making that first, very difficult and daunting appointment to discuss your weight.

Here are my tips:

(I will use GP here as the person you are most likely to see first, but it may be that it is a nurse practitioner or other health care professional)

1. Choose who you see if possible.

It may be that this means that you wait a little longer, but use the receptionists or triage person on the phone who the best GP for you to see would be. If you use the internet, perhaps look to see if the doctors at the surgery have any special interests or have written on the topic anywhere. Ask a friend or relative at the same surgery if they can recommend someone that they have seen, because even if it was about something totally different, their experience may help you choose who you might feel most comfortable seeing.

2. Try to learn a bit about obesity before you go – knowledge is power

You may know more than the doctor. We can’t know everything, and obesity is such a fast-moving area of medicine that your GP may not be up to date. Use social media, reading such as this https://www.nhs.uk/oneyou/be-healthier/weight-loss/ …

and up to date sources of information such as http://www.mdbriefcase.net/uk/obesity (which is aimed at health professionals but is accessible to non-medics as well) to learn about the science. Remember though that doctors do have a lot of knowledge about a wide range of things so even if

obesity is not their expertise, do approach it as a discussion rather than instruction and hopefully the GP will show you the same respect in knowledge-sharing.

3. Know what you would like out of the consultation

GP appointments are only 10 minutes long and it is important that you think about what kind of help you would like from the appointment. Would you like a referral to weight management services, would you like access to psychological support or referral for an exercise programme? Do you need treatment for a problem related to your obesity? Do you just want a chat?

Knowing what you think might be useful to you can help direct the conversation to ensure you come away feeling supported.

4. Know what is available on the NHS

Unfortunately, different areas of the country have different services commissioned for obesity which can make it confusing.

All areas should have a weight management service based on different “Tiers of care” with Tier 2 being diet and exercise, Tier 3 being diet, exercise and possible medications and Tier 4 being bariatric surgery. Usually one has to access each tier in order. Each tier may be provided by different organisations.

Ask what is available in your area and have realistic expectations of what your GP can organise for you.

5. If it all starts going wrong……politely leave

There will be two people in the conversation and despite your best efforts it may not go entirely to plan for reasons beyond your control. If you find that it is beginning to make you feel uncomfortable and upset, then it may be that ending the chat is the best way forward for both parties. Politely say that you don’t feel this is going well and that you will perhaps come back to talk about it another time.

This topic is an emotive one. I have had some “interesting” discussions with people with very entrenched views on the matter. What matters though, in the end, is that people with obesity can access timely, evidenced based treatment that empowers them to live the healthiest life they can sustain at whatever weight that may be.

Please do join me for our #obsmuk twitter chat at 8pm (UK time) on Wednesday 26th September to talk more about accessing care for obesity.

The questions that we wish to discuss are:

1.  What experiences have you had of approaching a health care professional about your weight?

2. What sources of information have you found useful in learning about obesity?

3. What makes the experience of discussing weight with a healthcare professional a positive or negative one for you?

4. What things would you like your HCP to know about being a patient with obesity?

5. What positive and negative experiences have you had of weight loss services? 

Dr Stephanie deGiorgio