"I Miss Hiking" - Metabolic Health (Part I) Artwork

Primary Care Pearls

A medical education podcast focused on primary care made by learners, for learners and - most importantly - led by our patients' stories. Episodes released every two weeks.

All Episodes

Primary Care Pearls

"I Miss Hiking" - Metabolic Health (Part I)

January 09, 2023 • PCP • Season 1 • Episode 14

In this episode, Dr. Vasudevan and Dr. Moreno unpack our patient's experience with weight and how it's impacted his life.

Share your reactions and questions with us at Speak Pipe . We might feature you on a future episode!

=== Outline ===
1. Introduction
2. Chapter 1: Personal Relationship to Weight
3. Chapter 2: Impact of Weight on Mental Health
4. Chapter 3: Relationship with PCP
5. Conclusion

=== Learning Points ===

Commonly used measures of obesity include BMI and waist circumference. These measures are imperfect, since they are attempting to quantify adiposity.
Patients often undergo an emotional journey that is related to their weight. Many patients prefer to move towards tangible end goals such as increased mobility, lowered risk for future adverse health events, or other factors rather than a specific weight, BMI, or waist circumference.
Screening and treatment of mental health conditions such as anxiety and depression can be instrumental in the care of patients who have elevated BMI.
Be sure to ask permission to discuss the patient’s weight before jumping in. Set SMART goals with your patients and set expectations early.

=== Our Expert(s) ===

Dr. Jorge O. Moreno is an Assistant Professor of Medicine at Yale School of Medicine.

Dr. Moreno is originally from Mexico and is also fluent in Spanish. He grew up in New Rochelle, NY and completed his undergraduate degree at Columbia University in 2006. In 2011, he obtained his medical degree from the University of Rochester School of Medicine and Dentistry. He completed his internal medical residency at the Yale University’s Primary Care Residency Program Yale New Haven in 2014.

=== References ===

Hales CM, Carroll MD, Fryar CD, Ogden CL. Prevalence of obesity and severe obesity among adults: United States, 2017–2018. NCHS Data Brief, no 360. Hyattsville, MD: National Center for Health Statistics. 2020. Retrieved from: https://www.cdc.gov/nchs/products/databriefs/db360.html
https://www.cdc.gov/obesity/data/adult.html

*For additional resources discussed in the episode, check out our transcript!

=== About Us ===

The Primary Care Pearls (PCP) Podcast is created in collaboration with faculty, residents, and students from the Department of Internal Medicine at the Yale School of Medicine. The project aims to create accessible and informative podcasts about core primary care topics centered around real patient stories.

Hosts: Nate Wood
Producers: Helen Cai, JW, August Allocco
Logo and name: Eva Zimmerman
Theme music and Editing: Josh Onyango
Other background music: Emily A. Sprague, Unicorn Heads, Godmode, Corbyn Kites, Ammil, Coma

Instagram: @pcpearls
Twitter: @PCarePearls
Listen on most podcast platforms: linktr.ee/pcpearls

Metabolic Health Compiled Episode (Part I)

[00:00:00]

[00:00:00] Introduction

Nate: hi everyone. And welcome to primary care pearls. A podcast made by learners for learners. And most importantly led by our patients stories. Today,

Patient: you know, I think if you look at someone my size or larger. I think that you can, I think it's safe to say that there's something emotional going on in their head with why they're that size.

Nate: we are talking about obesity part one in our metabolic health series. Obesity has become an in increasingly widespread health issue. Jorge Moreno: by 2031 and two of the patients that all of us see in the practice will be a BMI greater than 30.

Unfortunately that's where we're heading. So 50% of the us population will have a BMI greater than 30 by 2030. So that's hard to say hard to see, but it's, that's just a reality of where we are [00:01:00] right now. We're at 42%, so we're not really that far off.

Nate: Over the past 20 years alone, the prevalence of obesity has increased from 30% to 42%. Patients living with excess weight are more likely to suffer from conditions such as heart disease, stroke, and type two diabetes, which are often debilitating. If not fatal.

During our discussion will be joined by Phil, a patient, living with obesity.

Patient: I am 53 years old. I have been in Connecticut for a few decades originally from Colorado.

Nate: Through his experience, we'll learn more about the adverse health effects of excess body fat and the role that trauma and psychosocial distress can have both as a c ause and an effect of obesity. We'll also [00:02:00] be joined by an obesity medicine expert, primary care physician, and, and, uh, after all those hours I spent with him in the clinic.

I can say an all around great guy from the Yale school of medicine, Dr. Jorge Moreno.

Jorge Moreno: my name is Dr. Jorge Moreno. I'm an assistant professor of medicine here at Yale school of medicine. I've been at Yale on and off since 2014. I was a a resident in the that a primary care program. And I did some community private practice after residency for a couple years.

And then I came back and now I'm faculty at the medical school in the general internal medicine section

Nate: Our conversation will also be facilitated by a couple of friends and colleagues. First resident interviewer, Dr. An Vasu David,

Anita Vasudevan: my name is and I'm one of the residents in the Yale primary care program.

Nate: as well as medical student interviewer, Helen SI.

Helen Cai: my name is Helen. I'm a student here at the Yale school of medicineNate: Our discussion is going to be pretty far reaching. We're gonna be talking about a lot of the things that matter most to patients and providers when it comes to obesity. But some of the things that you can expect to hear are more about the strengths and limitations of the current metrics we use for measuring adiposity and something that's not talked about. We don't think nearly enough, the relationship between weight and mental health. my name's Nate wood. And I'll be your host for this episode. We hope that through this discussion, we can all become more confident in not only recognizing patients with obesity, but also in supporting them and offering treatment options.

For some of us, that's going to mean developing new approaches to discussing weight, manage with our patients so that we can be sure to do this in a way that makes them feel comfortable. And for others of us that might mean becoming more familiar with the treatment options for obesity. I hope we're able to do both

[00:04:00] before we get started, please know that this content is meant to be for learning and entertainment purposes only, and should not be used to serve as medical advice. If you, or a loved one is suffering from anything covered in today's episode, be sure to discuss it with your medical provider now onto the show.

[00:04:20] Chapter 1: Personal Relationship to Weight

Nate: Let's begin by hearing a bit from Phil about his personal journey with his weight.

Patient: I've been on a weight loss journey for most of my life. that's something I've always struggled with and my whole life I've been up and down the spectrum.

at the height, I was 425 pounds.

And working with my primary care He suggested some changes. And luckily it was at a time when I was receptive to that

Patient: I was tired of being sore. I was tired of my joints, always hurting. I had already been working with an orthopedist about problems with my knee. And I was too young to need a knee replacement.

I wasn't ready to give up on life because if I had kept down the track, I was, it wasn't sustainable. Eating the way I was wasn't sustainable in any way, shape or form

I miss hiking. I really miss hiking. I haven't been able to do it for [00:06:00] two, two or three years now because of circumstances. And all I want to do is go up to sleeping giant on, you know, in the spring in April and hike, hike up the tower trail. That's all I want to do.

Helen Cai: what else does a healthy fill look like for you?

Patient: a healthy Phil is being able to do those things that I haven't been able to do that I've talked about, you know, not having to, not having to ask friends for help, if friends helped me. Great, but not having to rely on them.

Nate: Phil's weight journey has been ruled by that number on the scale. But as you can hear, in his words, his journey with obesity is about so much more than just that, but sometimes that number on the scale is all that we see as primary care providers.

We don't hear about how it's impacted their life. We don't hear about the hobbies that they're no longer able to enjoy because of their weight or something [00:07:00] that they've lost because of obesity that they want. Nothing more than to gain back in the primary care clinic. We need better tools to help define obesity and understand our patient's weight journey. Dr. Moreno has some suggestions for where we might begin.

Anita Vasudevan: when you're sitting down with a patient, how do you determine whether they're obese or not?

Jorge Moreno: there's no measure that's perfect for obesity, but the most commonly used measure for obesity in the obesity literature in general is a BMI body mass index which is basically a calculation of the patient's weight in kilograms over. They're heightened meters squared, and it's just a calculation and it gives you a number.

Waist circumference as another measure of obesity is also helpful, especially because in [00:08:00] includes a measure of central adiposity, which can be very important in the patient health conditions

and so basically, the more common definition is if someone is overweight if they are with a BMI greater than 25 outpatient suffers for obesity of their, have a BMI greater than 30. And so that's that's usually the cutoff.

But like I said, no measures. Perfect. So sometimes if you have a patient with a very high muscle mass percentage compared to their fat mass then it becomes difficult to interpret the BMI because they might have a high BMI, not necessarily be at risk for the the risk factors with increase adiposity or excess weight.

Anita Vasudevan: as our patient described in his interview, he often comes back to the impact that his weight has had on. Knee pain. And you just alluded to some of the general sequella of having that excess adiposity. Can you describe what it is that makes excess weight? So.

Jorge Moreno: the problem in patients with obesity really stems from the [00:09:00] excess subcutaneous fat or visceral fat. So that's the adiposity that we're talking about because that's, that really drives a lot of the problems the chronic medical problems that develop.

So a patient with increased capacity central capacity can develop diabetes can develop osteoarthritis obstructive sleep apnea increased incidents of coronary artery disease. and there's various mechanisms for this to happen. In our patient that was interviewed he had increased mechanical stress of his joints, which can lead to osteoarthritis. So this increase mechanical stress can produce earlier osteoarthritis than one would expect.

Nate: Okay. Thanks to years of research, we now have a better understanding of how obesity leads to so many of these health consequences.

And so many times we think of. Adipose tissue as something that is inert or not active. Right. And so I think that the data has shown that there's a lot of hormones. the adipocytes, they basically produce adipokines, which are these other hormones that can create inflammatory cytokines, such as TNF alpha.

And so these cytokines create a low level inflammatory state in patients that have increased [00:11:00] adiposity. And as they increased weight, the body stores excess fat. And so that's where you get the increase at a post issue. And so. Is really a main driver For patients developing obesity

[00:11:14] Chapter 2: Impact of Weight on Mental Health

Nate: And for so many of us, as clinicians, as people who are hard science oriented, that is our understanding of obesity.

Those pathophysiologic me ISS that lead to this disease state. But that is not how patients think about excess weight or obesity. A patient's journey with their weight is much more complicated and personal with its own unique ups and downs. And for many patients like Phil, those ups and downs can really take a toll on mental health.

Patient: it's really important to not focus on that scale number so many times, because you know, that that's something that has taken me many years to learn is that the scale is not your master. It's a metal monster.

And all of a [00:12:00] sudden it's been flipped in my head in the last few months that two 80 is a magic number because it means less stress on that knee. It means a change in. And the risk odds for the surgery. It means a change in risk for recovery because of the weight put on my remaining, I would say good joint, but not good joint because the other knee will be replaced eventually too.

So in this case, the number does matter

Nate: even though obesity is observed in physical attributes and measured by things like that number on the scale, that is not what seems to be most important to the patient, but rather what that number represents. Does it represent mobility? Does it represent risk? Does it represent freedom? In the case of many patients, that number can become inextricably linked to their feelings of self worth.

Helen Cai: can you tell us a little bit about what that [00:13:00] journey has been like emotionally, you know, kind of accepting that the number doesn't matter, then going back to being told that it does mean

Patient: the idea of, of having to flip the switch in your head from being able to ignore the scale after, after so long listening to it, to all of a sudden having a professional, tell you for legitimate reason that the scale matters was really difficult.

It took a toll on me emotionally. And I don't want to say that it sent me spiraling, but you know, I mentioned I take meds for depression, anxiety, it ratcheted up my anxiety. when I went in for a follow-up with my knee doctor in September, I told him that I was having anxiety issues all weekend.

[00:14:00] even though I've gotten all these other great accomplishments, like, you know, I'm dropping pants sizes and dropping shirt sizes, I feel better. I have more stamina. I can do things in the gym that I couldn't do before. Those didn't matter to the one really important thing in my life, which is to replace this need because my pain base threshold is it about a sixth every day right now and if the knee doesn't get replaced, it gets worse. So it led to a lot of anxiety.

Nate: Okay. So when we talk about weight with our patients, we have to remember that we're talking about so much more than just a number obesity. Isn't a disease that develops overnight. So when we have a patient who comes into one of our clinic rooms with excess weight, we have to remember that this is something that they've most likely been [00:15:00] dealing with free years. And in some cases it may be something that they've been dealing with even since childhood.

Jorge Moreno: Sometimes you have patients that go through their childhood, adulthood suffering from stigma, whether it's at school for children or whether it's at work or at home. It's one of the main Culprits in their mental state, right?

Like they they've gone through their, their life kind of being many times bullied in a way to really affect their mood. And so I don't think that there's one path to obesity.

Jorge Moreno: I think that [00:16:00] every patient has had different variables in their life that has contributed to where they are when they see you in the office.

Patient: There's like five or seven different things that are considered to be once in a lifetime events or few in a lifetime events. One of them is like you get divorced, you lose a parent, you move, you come out of the closet. Your, your favorite dog dies. And I had all five of those happen in nine months.

Patient: So getting divorced from my ex-wife and coming out where huge part of that was that all of my friends at that point, her, her friends. So I lost an entire support system at that point and had nobody to help prop me up. And what I did have was food. Food was great and food tastes great. Who doesn't like food.

And it was, it was very comforting. Nothing. I had nothing else to come for me. Food and alcohol, alcohol has a lot of calories in it and that just sort of continued to creep up, even though that's when I met my husband 17 years ago. And it just continued to creep up and up over the years. My physical and mental wellbeing took some hits[00:17:00]

Jorge Moreno: obesity is a complex disease, that it's not their fault. In many times the patients have teared up in the room because it's the first time someone has told them that suffering from obesity is not their fault. Cause you know, the common trend is the patient is eating too much. The patient is not eating fruits and vegetables. The patient's not exercising enough. It's always about blaming the patient. And so I try to take. Guilt off their chest, because it really creates a whole different environment in the interaction.

Patient: That's what I love about the care team here is that. About finding and celebrating the successes. Never a blame game.

Jorge Moreno: I [00:18:00] definitely screen for depression. I screened for anxiety. And if they meet criteria for medications, then we talk about that, right?And so you should have. Use a multi-disciplinary method to treat that right? t at least in our clinic, we have a clinical psychologist that works with our clinic, but you know, it's mental health therapists are very hard to find, but there are community resources available for patients.

I feel very comfortable treating the bread and butter anxiety, depression, that doesn't have additional complications.

you know Many times the depression, anxiety can be because they're overweight. Right? And so when you make your clinic room, a safe place to talk about these things, then they, feel better already. So you just have to really separate out whether it's the weight gain that is really driving their depression to that level.

And if it is, [00:19:00] then you can treat it with, something that would be weight control or, create weight loss, like buproprion.

Nate: In order to do this, we should take a patient centered history and screen for things like anxiety and depression. If these comorbid mental health conditions are present, we should be sure to provide appropriate treatment for them refer the patient to a mental health provider or in some cases, both

Anita Vasudevan: that's really helpful. Thank you. a lot of times I think we failed to kind of think about both of these things at th e same time, and I think it's. Maybe more important to addressing obesity than we would realize.

Nate: As providers, we routinely see ourselves as part of the patient's care team, an integral part, but I think we less often realize our role as part of the patient's support system. And of course we shouldn't be the only member of the patient's support system. That support system is much more effective if that extends also into their home

Helen Cai: are there any specific things that you support systems did or didn't do that either were very helpful or very unhelpful in these conversations?

Patient: They did a lot of great things. I'm very fortunate to have. A lot of people around me who care and love about me and who want to see me get healthier and that get healthier is by whatever definition I care to make it, [00:20:00] they don't wanna see me thin. They don't want to see me climbing mountains with a new knee.

They want to see me happy and all they care about is what's Phil's definition of how. And if it's me being able to stand at a grill for four hours and being able to cook great. Cause right now I can't right now, I have to have people help me. I have to do my food prep at a dining room table. Instead of the kitchen counter.

I have to ask my friend to finish off the stakes because I can't, I can't clean up dishes after, after dinner. My husband has to do that.

Helen Cai: Sounds like you have a really wonderful. Care team around you though.

Patient: I'm very fortunate. I wish everyone was able to have this kind of support system.

Nate: If we, as primary care providers want to take the most comprehensive care of our patients with obesity, we have to think not just about the disease, but also the potential implications that obesity can have on one's social life and mental health.[00:21:00]

. And finally, we should be sure to see ourselves as part of the patient's support network while also encouraging them to, oh, their support network, both at home and in their community.

[00:21:33] Chapter 3: Relationship with PCP

Nate: of course, all of this is easier said than done. And given the stigma that surrounds this disease, it can be really difficult for many providers to get into a mindset wherein they're able to speak openly with their patients who have obesity about the topic in a way that's both productive and approachable

Patient: Eating the way I was wasn't sustainable in any way, shape or form and having. [00:22:00] Family and friends who cared about me and having a great primary care doctor.

Who's like, you know, you've been putting on this weight over the last couple of years. You've come and seen me, you know, every year and it's been climbing up and I'm worried about you, Phil. And what I loved about it was it wasn't a perspective of judgment. It was never a judgment call. It was always a, we should do something.

Are you ready to try something? And I was, and that's when he prescribed a weight loss drug and recommended. I talked to Dr. Murano Dr. Morano and I have been in a relationship of monthly conversations ever since, and guiding me to some other different medications that we've tried.

Nate: Phil's story highlights just how important it is for us as providers to think about the way in which we're approaching our patients who have obesity,

Anita Vasudevan:

Do you have any specific language or questions that you can offer us? Clinicians on how to bring up that conversation about a patient's weight with them in a way that's kind of trauma informed and sensitive to what history they may have gone through?

Jorge Moreno: Yeah, absolutely. So I, I think that way to think about a conversation about obesity or weight management , as a sensitive subject, such as like, when you take a sexual history, like it's a very sensitive topic. And I think we're really good at taking sexual histories because we're trained in that, but we're not really good at taking obesity histories or trajectory or received because we're not really trained in that. And there has been a [00:24:00] lot of data that medical students, PA students, residents are just not trained in how to approach it. So it's a great question. So what I do first, you always want to start on a good note. So if you look at the trend at the way trend before you go into the Office into the patient's room.

You may notice that the patient had actually been trying to lose weight and they actually lost five pounds before they came to see you. But because sometimes we just focus on BMI or their weight is still, considered to be high. We don't acknowledge those small victories.

Right. And so, imagine just walking into the patient's room and asking their permission to discuss their weight. That's like, step number one is you have to ask their permission if they want to be discussing that during that visit. And so once you've asked the permission, you've just found out that they lost five pounds and you can bring that in and tell them, you've noticed that because a lot of times, they may feel like they haven't got an acknowledgement that [00:25:00] they've made an effort. And so that kind of sets the positive tone. You've read their chart or, whatever the case may be like, if they have high blood pressure and they they've been in the hospital how do you feel about this? Bringing it from the perspective of you care about them and you care about their medical conditions and you want to make them better. So, what, what happened when you were in the hospital for that episode of hypertensive emergency or that bad episode of high blood pressure, how did you feel what was going on?

And so highlighting that episode will allow them to open up, well, you know, I'm really worried about my blood pressure. This has been really on my mind. My mother had kidney disease on hemo dialysis and you really searching for their motivation for change. And also be ready for them to say, no, I don't want to talk about my weight and moving on and saying, you know, I'm here when you are ready to discuss it. Because sometimes the [00:26:00] first time you broached the subject, they may or may not want to approach it.

In the Yale office-based curriculum I talk about the five A's of obesity counseling. And so the first a is asking, you know, there's five A's and they can be really used in any order assessing the problem. Really helping them agree to the plan. And it really just guides the conversation for them.

Jorge Moreno: So once we get to the ask phase and they're really in engaged in the conversation about change really kind of setting expectations is really important. Expectations for you in terms of like your availability and how you plan on keeping them somewhat accountable for what you guys agree upon and acknowledging [00:27:00] that there's ups and downs. A lot of times during the encounter, if they're coming up for a follow-up visit, they feel that they haven't They feel almost sad or like at fault for not losing weight because we had agreed on something and so I use that opportunity to talk to them about the fact that obesity is a complex disease, that it's not their fault.

it's just like diabetes, right? we're, we're we don't tell a patient, it's your fault you have diabetes. we talk to them, you have diabetes, we're going to help you figure out how to control your glucose. So controlling your diabetes will prevent kidney disease. And so that's exactly the approach I take with patients with obesity . And we should try to take away the stigma that's been there for hundreds and hundreds of years, and really take it from that perspective because you'll, you'll be much more [00:28:00] effective in your interactions when you talk to patients.

Helen Cai: Can you tell me a little bit about their approach to your medals?

Patient: So I have a great relationship with both my original primary care Dr. Ellis and, my weight management doctor, Dr. Morano. I love that they're in the same practice with each other, so they talk to each other, they know each other

Everything has been revolving around either a regular checkups with Dr. Ellis and I've switched to six months because we want to keep an eye on my weight loss and a couple of other things.

And you know, I'm on, I'm on some meds. So we want to make sure that there's no. Interactions with any of the meds and any blood or kidney or liver issues. So we do regular checkups. And with Dr. Morano, we have a monthly televisits meeting where we go over, you know, where you at? How are you feeling physically?

How are you feeling mentally? How are you doing with the drugs or talking about what my drug supply issues are? And what's our plan for it?

Jorge Moreno: every practice is set up differently. All tell you how I kind of run my practice. I used the electronic medical record very well. In, in terms of patient messaging is very easy for, for us to communicate that way. So first for fall for initial visits I usually have closer followups.

Usually I do a four week followup in the early months to see that their Staying on task and staying and those goals. But I also give them the option of sending me a message every week or every two weeks. It's. [00:30:00] I give them the guidance that they can reach out to me when they want. This is not mandatory for them, but I, I tell them that if they'd like to send in their weight once a week or once every other week via the, the electronic medical record, they can do that.

It's just another way of kind of keeping tabs and it's quick, right? Like they lost the. You send them a quick note. Congratulations. This is great. Those little like positive reinforcement I find have been helpful for my patients and they'll might respond, you know, things for help or, they'll be happy to hear from you.

At least for me, it doesn't overwhelm me in terms of the cause of a lot of times the messages can sometimes be a lot, but that I think is a good, a good message to receive because they're losing weight and they're, they're doing well. And there's also times where the messages I'm not losing weight. If you have availability for like an urgent visit that you can squeeze them in and like just kind of talk to them about what's going on, then you can squeeze them in. So [00:31:00] basically other week they'll communicate with me in one way or another.

And then I see them. Now with tele-health being so available, they could either do a telehealth visit and we can talk about how they're doing that as well. And then as they're progressing and doing better, they've lost weight, they're stable, then you can space out the visits- months, three months and so on. But they always check in whether it's their weight or whether it's struggles, right. So expectations and just wanted to remind the listeners about the smart goals, right. You know, they're the acronym. You want to make goals that are specific measurable, attainable, relevant and time limited. Right. So that you want to create these goals for the patient. And the nice thing about spelling it out in your note is that, you know exactly what you're going to ask them next time. Right. So did you, did you walk, you know, 5,000 steps and [00:32:00] measure it with your apple watch during lunchtime at work?

Like very specific goals, because if you just say something like I'm want to walk more, it's not concrete and you, they don't fit it into their schedule. So we really want to know specific about those goals so that they can fit it into their schedule appropriately. And they're like, oh, I have to walk during my lunch hour or that's what we agreed upon.

And then next time you just asked, did you walk during your lunch time? And they're like, oh, I did a once a week instead of twice a week. So you have things to go off. That's what I do in my practice.

Patient: I've got a decent sized yard in suburbia and I do what I can. I mean, I can't do everything there, but I do what I can. I don't just sit on the couch. So there's still activity. I'm still, you know, I just show up, do the work, and they're very positive about supporting that they're positive about there not being any shame related [00:33:00] with still being 2 93 and finding the successes and helping me share those successes. That's what I love about the care team here

Helen Cai: Do you, do you ever feel like there were instances where you had a doctor who was trying to initiate that conversation, but you weren't receptive.

Patient: Yeah. I've had that experience with the doctor who I had the vertical sleeve with. And, you know, I had gotten down to where I was at two 60 ish. And as I was climbing back up and coming for my follow-up visits, it's like, you know, Phil, I think that you need to, you need to go on this in a huge deal. It was some radical things he was proposing and there were things I wasn't ready for, but they were the things that were in his toolkit.

Yeah. It was some very restrictive programs about liquid diets and, you know, 1100 calorie diets. And it was things that just scared me and he wasn't being um, shameful about [00:34:00] them. He wasn't suggesting, you know, he wasn't, I didn't feel like a failure in his eyes or anything like that. It just, he was suggesting alternatives that I wasn't prepared for that.

Nate: Phil emphasized how important his relationship was with his primary care physician. and Dr. Moreno for his part did a really nice job of outlining how he approaches his patients with obesity. First, always be sure to start on a good note, find something to your patient on and acknowledge small victories.

Then using the five A's model for behavioral change, ask permission to discuss the patient's weight before actually jumping in. Be sure to convey that you care that you're not judging them, that obesity is not their fault. And to remove stigma, get context, see why the pay patient might be motivated to change and leverage that for their benefit.

Be sure to set [00:35:00] smart goals with your patients and set expectations early and frequently for how your communication will be and what visits will look like going forward. Throughout this episode, I was really struck by Phil's vulnerability. Courage. Boldness and insight as he was discussing his journey with obesity, he spoke so vividly about the ways in which his mental health impacted his journey with weight and the ways in which his journey with weight impacted his mental health.

This really got me thinking about my personal relationship with the scale or as Phil puts it, the metal monster. And I hope it did the same for many of you too. even if we don't have obesity and especially if we do, we all have a story about our journey with our weight and how we feel when we step on the scale.

To suspend that [00:36:00] reality when we step into the exam rooms of patients with obesity is to do them a great disservice. Instead, we should draw on these personal experiences, our education and training, and our empathy to position ourselves as supportive care providers for our patients with excess weight.

Phil mentioned. One of his goals is to lose enough weight and to gain enough mobility, to be able to walk to the top of sleeping giant. One of our most beloved state parks here in Connecticut. And I can't wait to congratulate him when he reaches that goal.

[00:36:40] Conclusion

Nate: and that concludes our episode for today. Before we close out, I wanna leave you with some key points that I took away from this show, and maybe you can too.

First BMI can be a helpful tool to screen for obesity, but other measures such as waste circumference and comorbid [00:37:00] conditions like diabetes and sleep apnea can help us better identify when an individual's weight is a health risk.

Second obesity is a disease ease and a complex one at that numerous hormonal metabolic and neural factors can affect weight loss efforts. We must take a holistic multidisciplinary approach to tackling this public health issue, both in our offices and in our communities.

And finally trauma and psychosocial distress can be both a cause and an effect of obesity as providers we must be screening for as, as appropriately treating mental health conditions like depression and anxiety that are common among patients with excess weight.

Be sure to tune in next time, wherever you listen to your podcasts to catch part two of the metabolic health series, where we'll be discussing weight loss strategies, such as diets, medications, and [00:38:00] surgery, we hope you enjoyed this episode, which was made possible by contributions. Our patient, Phil, our resident interviewer, Dr. An vaso Daveon our medical student interviewer Helen SI. And Dr. Jorge Moreno who provided faculty peer review for the project and served as our expert. Special, thanks to our producers, August a Loco, Helen SI and Joshua Onono as well as our faculty advisor, Dr. Katie, Geason.

Be sure to follow us at PC pearls on Instagram, where you can expect to get sneak peaks, additional learning content, and the most up date details on show release times. Thanks again for joining us today. Farewell from all of us here at the primary care pearls podcast will catch you in the next one.