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Feb 6, 2024

Practice Perfect 898
Obesity Counseling for the Podiatrist

  Jarrod Shapiro, DPM, FACFAS, FACPM, FFPM, RCPS Glasg

PRACTICE PERFECT   February 6, 2024

As most of us know, obesity is one of the most significant contributors to poor health and is also at pandemic proportions. In my practice as a general podiatrist seeing patients of all ages, most of my patients are obese. I even have children presenting with conditions such as planus deformities with pain secondary to obesity. Some disorders such as plantar fasciitis are intimately related to obesity, and as much as we treat them with the best podiatric care available, without weight loss they are unlikely to fully heal. Similarly, I can’t recall ever in my practice life treating a patient with Achilles insertional tendonosis or calcinosis who wasn’t obese. My average BMI for these patients is in the high 30s, sometimes even mid 40s, and I recently had a patient with a BMI of 53 with severe calcification and tendonosis that required surgery.

Despite the commonality of obesity, I find this to be a very challenging aspect of care. First, as a person who became overweight in my late 30s, I’ve learned weight loss is not an easy pursuit. I’m about 30 pounds overweight but consider that patient who has 100+ pounds to lose. Second, there is a significant level of embarrassment for patients to discuss this topic. Most of those who are obese know they are and know they have to lose weight. Third, doctors don’t want to make their patients feel uncomfortable, so some of us are hesitant to discuss the issue.

I find obesity to be a very
challenging aspect of care
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The Challenge

With that said, counseling and supporting our patients’ attempts to lose weight and improve their health is an important aspect of our care for them. After scrolling through a number of sources as well as my own experience, here are some suggestions to help with your obese patients.

As a reminder, obesity is stratified as follows:

Weight status BMI kg/ms2
Underweight < 18.5
Normal 18.5 – 24.9
Overweight 25.0 – 29.9
Obesity ≥ 30
   Class 1 30.0 - 34.9
   Class 2 35.0 – 39.9
   Class 3 ≥ 40

Make the Environment Welcoming and Nonjudgmental

Make sure your practice location has a scale that is located in a private location and has a higher weight limit to avoid the embarrassment of “maxing out” a regular scale. Also, have chairs in the waiting room and exam rooms that can handle patients of greater size as well as larger blood pressure cuffs.

When speaking with patients, don’t use judgmental comments, keeping your discussion objective and neutral. Use words like “lower your weight” rather than “improve your weight.” Discussing BMI and waist size may be more objective than using words like “obese” or “fat”. Consider using phrases like “reaching a healthier weight range”. Consider also asking your patient for permission to speak about their weight rather than just blurting out their “problem.” Many times, patients will comment about their weight without being prompted, and I use this as an invitation to gently discuss how their weight contributes to their foot pain.

Counseling Methods

It’s probably obvious to say that we want to motivate and empower our patients with weight challenges since they are the ones that must do the actual work. It behooves us, then, to approach our counseling with that empowerment goal in mind. One published method to provide an overall structure to a counseling session is the 5 As of Obesity Counseling.

5 As of Weight Loss Counseling1

  1. Ask – Ask for permission to discuss weight.
  2. Assess – Assess the severity of the obesity, documenting factors such as BMI, waist size, and other comorbidities.
  3. Advise – Counsel the patient on the health risks of obesity, benefits of weight loss, treatment options, and strategies.
  4. Agree – Agree on realistic weight loss expectations and behavioral changes.
  5. Assist – Help the patient identify barriers to weight loss, communication with other healthcare providers, and follow up.

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Specific Recommendations

It is helpful to give patients specific information to take away from the encounter to help them focus on their weight loss goals. These may loosely break down into diet, exercise, and psychological issues. However, as podiatrists it is neither in our expertise nor easy to fit into a full encounter to do a lot of counseling. As such, I suggest focusing on helping patients become aware of obesity’s effect on their body, how it affects their lower extremity, and increase awareness of ways to get help.

Diet – I’m very quick to refer patients to nutritionists and certified diabetes educators. These providers have excellent suggestions to change eating habits while allowing one to continue enjoying food. I also try to counsel patients on simple methods to start decreasing calories, such as eliminating soda, drinking more water, and substituting vegetables for unhealthy between-meal snacks . Simply decreasing portion size can also be very effective.

Refer patients to nutritionists and certified diabetes educators

Exercise – This can be an especially challenging recommendation for the patient suffering from lower extremity pain. Weightbearing exercises such as walking may be difficult due to the current foot/ankle issue with which they are dealing. As a result, I suggest to patients nonweightbearing exercises such as biking, swimming, and seated weight training where appropriate.

Psychological – There are often a significant number of underlying psychological issues that underpin eating disorders, and although I am not trained to provide this kind of counseling, I can help patients eliminate the stigma of receiving help. It’s important for patients to be referred back to their primary care providers with suggestions to consider psychological counseling. For larger patients, it’s also helpful to mention the role of bariatric weight loss surgery as a potential option, being careful not to overpromise.

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With already busy schedules and a lack of time to focus on obesity, the average podiatrist doesn’t have the time to make the entire encounter about obesity (nor should we), but some discussion in a productive manner is very helpful. Good luck with your next obesity-related patient encounter.

Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]


References
  1. Vallis M, Piccinini–Vallis H, Sharma AM, Freedhoff Y. Clinical review: modified 5 As: minimal intervention for obesity counseling in primary care. Can Fam Physician. 2013 Jan;59(1):27-31.
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