What approach should I take when discussing weight with someone at risk due to their Body Mass Index (BMI)?

Patient-Centered Approach to Weight Discussions for Individuals with High-Risk BMI

When discussing weight with someone whose BMI puts them at risk, use patient-centered, nonjudgmental language and a structured approach that addresses health outcomes rather than focusing solely on weight itself. 1

Initial Communication Approach

• Use people-first language (e.g., "person with obesity" rather than "obese person") to avoid defining patients by their condition 1
• Provide privacy during weighing and treat weight as sensitive health information 1
• Establish a trusting relationship before broaching the topic, as this eases discussion 1
• Frame the conversation in medical terms by linking weight to relevant health concerns 1
• Use objective measurements like BMI as a starting point for discussion rather than subjective observations 1

Assessment Framework

1. Calculate and document BMI at each visit 1

   • Normal weight: BMI 18.5-24.9 kg/m²
   • Overweight: BMI 25-29.9 kg/m²
   • Class I obesity: BMI 30-34.9 kg/m²
   • Class II obesity: BMI 35-39.9 kg/m²
   • Class III obesity: BMI ≥40 kg/m²
   • Note: Asian populations may have different thresholds 2

2. Assess weight trajectory and pattern to inform risk stratification 1

3. Evaluate for obesity-related health conditions that increase cardiovascular risk 1:

   • Diabetes/prediabetes
   • Hypertension
   • Dyslipidemia
   • Sleep apnea
   • Nonalcoholic fatty liver disease

4. Assess readiness to make lifestyle changes before beginning comprehensive counseling 1

Specific Discussion Points

For patients with BMI ≥25 kg/m² with additional risk factors:

1. Clearly communicate health risks:

   • Explain that higher BMIs increase risk of diabetes, cardiovascular disease, mortality, and reduced quality of life 1
   • A systematic review of 203 studies with 6.3 million cancer survivors showed reduced cancer-specific survival and increased recurrence risk in those with BMI ≥30 kg/m² 1

2. Set realistic weight loss goals:

   • Aim for 5-10% weight loss, which can significantly improve health outcomes 2, 3
   • For cancer survivors and patients with diabetes, emphasize maintaining BMI between 18.5-24.9 kg/m² 1

3. Discuss the three-pronged approach to weight management 1:

   • Dietary modifications:

     • Recommend portion control and reading food labels 1
     • Suggest a plate method: 30% vegetables, 20% fruits, 30% whole grains, 20% protein 1
     • Advise a 500-750 kcal/day energy deficit for weight loss 1

   • Physical activity:

     • Recommend 150-300 minutes/week of moderate-intensity activity 3
     • Emphasize strength training to preserve muscle mass 1

   • Behavioral strategies:

     • Suggest self-monitoring of food intake, physical activity, and weight 1, 4
     • Recommend high-intensity programs (≥14 sessions in 6 months) 4

For patients with BMI 25-29.9 kg/m² without additional risk factors:

• Focus on preventing additional weight gain 1
• Discuss healthy eating patterns and regular physical activity 1

Follow-up and Maintenance

• Schedule regular follow-up to monitor progress and adjust strategies 2
• For successful weight loss, recommend at least monthly contact for a year to prevent regain 4
• Emphasize that weight maintenance requires ongoing attention to diet, physical activity, and behavioral strategies 5

Common Pitfalls to Avoid

1. Appearing judgmental or stigmatizing - This can damage the patient-provider relationship and reduce effectiveness 1

2. Setting unrealistic goals - Modest, sustainable weight loss (5-10%) is more effective than pursuing dramatic results 3

3. Focusing only on diet - Comprehensive approaches including physical activity and behavioral strategies are more successful 5

4. Neglecting long-term support - Weight regain occurs in ≥25% of participants at 2-year follow-up without continued support 2

5. Using ineffective communication techniques - Avoid phrases like "you should lose weight" and instead use collaborative language like "what are your thoughts about your current weight?" 1