Weight Management Counseling for New Nurse Practitioners
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Show notes:
Weight management counseling in primary care is such an important skill, and it’s truly the foundation that patients need before we can start addressing weight loss medications.
In this week’s video, I’m covering my approach to weight management counseling in primary care, which will hopefully help you feel more confident in your visits.
Weight Management Counseling in Primary Care
I cover:
✅ How to talk to patients, including actual easy scripted phrases to use so you get the information you need and they feel supported
✅ Special considerations with using the BMI calculator (who knew??)
✅ One key to actually move the needle forward in weight management conversations
✅ The hidden beliefs we need to address with patients that will set them up for success
✅ The mindset shift that will help you and your patients set realistic expectations and plans of care so they reach their goals
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WEBVTT
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Hey there, welcome to the Real World NP podcast.
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I'm Liz Rohr, family nurse practitioner, educator, and founder of Real World NP, an educational
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company for nurse practitioners in primary care.
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I'm on a mission to equip and guide new nurse practitioners so that they can feel
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confident, capable, and take the best care of their patients.
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So the conversation that's been coming up more recently is that either in a physical
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context or someone coming in for their annual physical or like a doorknob question on my
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way out after there's a routine visit that they have, just asking, oh, can I, could
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I take some weight loss medication, which is I'm totally down for that conversation.
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And it's a much larger conversation than a five second like, hey, you're on your
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way out and I'll give you this medication and bye, see you later, right?
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That doesn't feel responsible to me.
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So what I usually say to patients is that I would love to help you with your weight goals.
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It is a longer conversation than unfortunately we have time for right now, but let's schedule
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the next available time that you can come in.
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We'll sit down.
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We'll have a conversation about it.
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We'll come up with a plan because there are many options.
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So I usually start with that.
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So hopefully that script can help you if this question is also coming up for you.
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And then I just want to talk about the kind of foundation of the conversation and
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things to be mindful of, what to watch out for, how to have the conversations, things like that.
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So weight management conversations can be a little bit sensitive for patients.
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So when I'm talking about it with patients, I am being very mindful.
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Well, first, I guess, first off, before I even get into the conversations to have
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with patients, two foundational things I really want you to keep in mind.
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So when we're talking about body weight, fortunately or unfortunately, medicine is very
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And it is very factual, hard and fast numbers and rules and algorithms, which can be very helpful.
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However, it's also important to recognize that even with those hard and fast rules and numbers,
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there is gray area in medicine.
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So specifically what I'm referring to here is the body mass index number.
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So when it comes to weight management, we're talking about body weight.
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And we're also talking about that height and weight ratio, the BMI number that's calculated.
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So just fun facts.
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This was developed in the 1800s by a mathematician for research purposes related to government
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funding, if I remember correctly.
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But however, this person was not a medical person.
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This was a formula that this person created and decided that there was a range to describe
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people's body weight.
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And so in current modern medicine, what we understand is that a BMI range of 18 to 24,
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Approximately, depending if we're talking about cis male or cis female patients, we
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don't really have translations for trans male or trans female patients or non-binary
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patients.
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However, the general consensus is around those numbers is the quote unquote ideal
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body weight.
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Between 25 and 29.9 is considered to be quote unquote overweight.
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And 30 plus is considered to be in the obesity status.
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And then there's other levels beyond that.
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However, remember, this was based on a formula that someone created.
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And so the general consensus of what we think in medicine is that an elevated BMI
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outside of the quote unquote ideal range can be associated epidemiologically with
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increase in comorbidities, hypertension, diabetes, et cetera, et cetera.
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And there are some conditions that can correlate.
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However, I think, in my opinion, is that in medicine, we tend to be too hard and
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fast with that and automatically associate a BMI of greater than 25 or greater than
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30 with quote unquote unhealthy, when in fact, it is more nuanced than that.
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And there can be healthy patients with a BMI in that range.
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There can be unhealthy patients in the ranges of 18 to 24.
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So I just want you to keep in mind that this is something to consider, but
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it is not this hard and fast rule.
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Because the other thing that I want to talk about as it relates to weight
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management is that there's a lot of stigma and bias and we all have stigma.
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We all have biases.
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It just happens.
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It's just the culture that we're in, regardless of where we live.
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So there's a lot of fat phobia that is really important that we are very
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mindful of in our own practices in all types of biases.
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But in this video, I'm specifically talking about that because a lot of
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times the way this pops up is that patients who have a BMI of greater than
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30 or greater than 25, they have been labeled as their body weight is the
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sole reason for all of their medical problems and they are denied workups.
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They're denied the care that they deserve simply because a provider
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looks at their body weight and then decides that that is the reason
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for their medical condition, which again can be correlated, right?
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But it's not necessarily causative.
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So I just want, I just want to start by having that conversation
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with those two things to keep in mind.
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So when it comes to the actual conversations with patients, so it
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depends if they're bringing it up to me or if I'm bringing it up to them.
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If I'm bringing it up to them, I always ask permission.
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I always ask permission in general when it comes to weight, when it comes
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to reviewing lab results, when it occurs to anything, right?
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Cause it's their body, it's their life.
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Right.
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And if I ask their permission, it's clear or not whether or not they
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feel comfortable having that conversation.
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Is it okay with you if we talk about body weight?
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Yes or no.
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I'd really rather not talk about that.
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Okay.
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Well, maybe at another time we can talk about that.
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Right.
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End of, end of conversation.
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Oh yes.
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I like, I'd really love to talk about that.
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I've been really struggling to lose weight, right?
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There are many alternative responses that they can have, but you
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can kind of gauge where they're at.
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The other thing is to come in with asking questions because I think,
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especially because we're short on time, we want to do things like, you
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know, just, just say a thing and then make a recommendation.
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Hey, your body, your BMI is 30.
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I recommend you lose some weight.
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Bye.
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See you later.
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I don't say that, but I see that a lot in, in primary care
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in the notes that I read.
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I mean, not the colleagues that I have right now are amazing, but, um, in
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historically speaking, people tend to approach body weight in that way.
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Whereas the approach that I recommend that is very patient centered that
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actually feels like it moves the needle forward a little bit more in
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terms of the patient's goals and optimizing their health is asking
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questions because we don't know.
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Maybe they've been struggling with their weight.
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Maybe they've been trying to lose weight.
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Maybe they exercise, um, five days a week doing strength training
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and cardio and they have a low carb diet where they eat a ton of vegetables.
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How do we know until we ask, right?
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So, um, what is your, what do you, like, how has body weight been for you?
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What kinds of things have you tried?
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How are you comfortable with your weight?
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Have you been trying to lose weight?
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I've been trying to gain weight, um, et cetera, et cetera.
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What are your, like, what are your health goals?
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It's a longer conversation, but the more questions you ask, the
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more information you get, and then you can target your
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conversations going forward, right?
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So when it comes to the actual interventions with healthy, quote
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unquote, healthy lifestyle, and I say that in quotes, because there
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are many definitions of what is healthy.
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And it also, you have no idea what the patient thinks is healthy
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compared to what you think is healthy, right?
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So asking questions about what they currently have for a diet.
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What does their general diet look like in 24 hours?
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Yesterday, dietary recall, that kind of thing, right?
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What kind of exercise, are you doing any kind of exercise these days?
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Are you walking?
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Are you gardening?
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Are you swimming?
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Those kinds of things in a very open and non-judgmental way.
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Cause that's, we're not here to judge.
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We're here to help, right?
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So anyway, I clearly have some feelings about this topic.
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Um, but, um, I asking the patient, um, I get, again, getting the
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history of what they're actually doing and then making
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recommendations based on that.
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So when it comes to healthy diet and lifestyle, current CDC
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recommendations in the U S as it relates to exercise is about
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150 minutes per week of moderate intensity exercise.
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So you can look that up on their website.
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They have various categories of what's considered moderate
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intensity versus high intensity, et cetera, et cetera.
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So that's the general consensus.
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Another thing I want to say about data and medicine is that it is much
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easier to get the highest quality evidence with a randomized, double
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blind controlled trial of a summer pharmaceutical agent than it is for
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a lifestyle modification or my lifestyle intervention study, right?
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So keeping that with a grain of salt, that's why we don't have
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one diet that works the best or one type of exercise that works the best.
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Right?
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So that's the general consensus as it relates to exercise,
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assessing what they're currently doing and what they're open to and
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having that conversation.
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The other thing as it relates to dietary healthy lifestyle is there
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is a lot of options.
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So the most studied options are the Mediterranean diet and the
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DASH diet that doesn't mean that's the only one that's available.
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The other recommendation from the CDC in the U S is the plate method
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where half the plate is fruits and vegetables.
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And then the other half is complex carbohydrates instead of simple
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carbohydrates.
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And then the other kind of quarter portion is some sort of protein that
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is lean, whether it's animal source or vegetarian sourced.
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And then the general rules globally is to avoid excess sugar, fried
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foods, processed foods, et cetera.
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So there's a lot of options there, right?
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That's a long conversation to have with a patient.
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And if we try to give patients at weight loss medications without
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understanding where they're coming from, it's not going to be as
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effective or we give them a weight loss medication, it will work while
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they're taking the med.
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And then as soon as they stop, the weight will come right back.
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And we don't want to do that for patients.
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That's not helpful in the long run.
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I think that the general cultural paradigm perspective that I,
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patients don't necessarily say this, but I can read between the
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lines and I live in the U S and I see the cultural messaging, right?
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Is that people think that if they take a medication, they're
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going to drop all their weight.
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It's going to be solved.
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They will arrive.
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It will be much better, right?
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And that's not really how that works.
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So that's the kind of like understanding of the background.
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And it depends on the cultural perspective of the patient that
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you're talking about.
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And it also, again, and when it comes to dietary things, what is
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the typical food that that patient is having?
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Are they Thai?
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Are they Dominican?
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Are they Brazilian?
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Are they having Brazilian, um, what kind of like, are they
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eating traditional Brazilian food or traditional Dominican food,
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et cetera, et cetera.
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And how can you adapt those things to their lifestyle, right?
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This is a little bit complicated.
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And, and it's not to say that I'm not saying that to discourage you,
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but when you're a new nurse practitioner and you're in this
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situation and someone just wants a weight loss medication to lose weight
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now, it's on us to have that conversation with them of we can, I'm
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here to help you meet your goals and live your best life and feel
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the best that you can.
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And also this is not a one-time thing.
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This is not a one-time visit.
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This is a process and it takes a lot of time.
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And it doesn't matter if we get to your weight now or in
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two years from now, right?
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Like for me personally, I'm working on strength training.
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I'm working on physical therapy and I resist it.
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I don't want to do it and I still do it.
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And even though I'm not doing it like a hundred percent every single time,
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because I'm still showing up every single day, I'm stronger.
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And it's a pleasant surprise, right?
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And it's the same thing with your patients when it relates to weight
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loss, it doesn't matter if they don't do a hundred percent all the
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time right now, just show up, just try it, see how it goes.
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Right.
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And then I think the other thing, and when it comes to goal setting,
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that's one of the things I like to talk about with patients too.
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What are your goals here?
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Because some people have this idea that they want to lose 50 or
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a hundred pounds tomorrow.
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And what we've generally found, the guidelines is about, I'm
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forgetting this, but I believe it's between two and five percent
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in the course of six months.
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And then the goal is to lose about that much weight and then take it
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from there instead of like a, instead of like a steep decline right away.
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And then maintenance, it's more of like a gradual, okay, let's do a
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little bit, maintain it a little bit more, maintain it a little bit more.
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Right.
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I mean, this is patients lives, right?
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And I think when I was a new nurse practitioner, it's so pressing
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because you're brand new.
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You haven't seen this before.
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You haven't been doing this for five years.
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You haven't seen the trajectory of developing a panel and developing
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relationships and seeing how things progress over time.
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But trust me, this, you're not going to solve their problem today.
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You're not going to solve their weight loss today.
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Right.
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And hopefully that will be helpful for you to keep in mind, both with
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expectation setting for the patient, but also expectation setting for yourself.
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It is a process and we need to communicate that with patients and it's
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hard, right, because they live their regular lives, they work, they might
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work, they may or may not work.
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Right.
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But like, it depends on the situation of the patient.
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We can do telemedicine visits.
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We can do monthly check-ins.
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We can do check-ins every three months.
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Right.
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So anyway, I have some clearly have some feelings about this, but I
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just, hopefully that's helpful for you for having that conversation with
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patients, because for patients to take weight loss medications, we need a
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first of assessing where their dietary interventions are, assessing where
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their physical exercise interventions are.
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What are the ways that we can optimize those?
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What are the potential levers that we can pull to help them?
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What is their understanding?
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Maybe they don't understand that they, they, they, you know, maybe
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they're drinking fruit juice every single day, three times a day.
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Right.
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And that right there is a potential intervention to reduce the caloric
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intake, as well as reduce the sugar intake for that patient, because
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that's more in line with the general consensus recommendations of health
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conditions, right?
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So anyway, hopefully this video was helpful.
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Please let me know what questions you have.
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And next week I'll be talking about weight loss medications, the main ones
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that I am familiar with, that I use in my practice, the other options that
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we have, yeah, fun stuff like that.
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And the monitoring all that.
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So anyway, thank you so much for watching.
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Hang in there and I'll see you soon.
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That's our episode for today.
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Thank you so much for listening.
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best care to their patients.
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Take care and talk soon.
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