As a family physician for many years, I’ve become accustomed to the ever-evolving landscape of diet, nutrition, and weight loss interventions. Patients often look for immediate solutions to longer-term weight challenges, from fasting and fad foods to more recent medications like glucagon-like peptide 1 (GLP-1) agonists and bariatric surgical interventions. I’ve learned that effective counseling on these topics requires a delicate balance of empathy, evidence-based information, and a focus on overall health rather than just numbers on a scale. This includes using shame-free language, addressing misinformation, and fostering lasting changes in eating habits while incorporating well-established behavior change models and coaching techniques. The role of empathy in this process cannot be overstated, as it forms the foundation of a solid patient-practitioner relationship. Below, I offer a few productive strategies for helping patients wade through the murk of weight management without engaging in harmful behaviors.

1) Offering Shame-free Counseling

Creating a shame-free environment is not just good practice, it is crucial when discussing diet and weight. Shame is not only ineffective as a motivator but can also be deeply harmful to patients’ mental and physical health. It may contribute to people’s ongoing weight challenges. I once had a patient recall that a previous doctor had told her that it was irresponsible of her not to lose weight — without recognizing that she had been trying to do so for many years. This same patient felt embarrassed by having to stand on the previous doctor’s hallway scale, where passersby could easily read her numbers, and by having to squeeze into the previous doctor’s older office chairs, which were narrower than most. This constellation of experiences caused her to avoid medical visits for many years.

To ensure your counseling is shame-free, I suggest the following:

1) Use person-first language: Say “person with a diagnosis of obesity” rather than “obese person.” Some people prefer the descriptor “person who carries extra weight.”

2) Focus on behaviors rather than body size: Discuss eating patterns and physical activity rather than weight.

3) Acknowledge the complex factors influencing weight: It’s not just about personal choices; it’s about genetics, environment, and socioeconomic factors. All play a role in how much a person weighs.

4) Celebrate non-scale victories: Improved energy, better sleep, and increased strength are all worthy goals. By focusing on these achievements, we can instill a sense of positivity and encouragement in our patients, motivating them to continue their journey toward better health.

2) Working Within a Transtheoretical Model of Change

The Transtheoretical Model of Change (TTM) is a widely recognized behavior change framework. TTM recognizes that patients go through several stages before successfully modifying any given behavior. These include: pre-contemplation, contemplation, preparation, action, and maintenance. Understanding where a patient is in this cycle is helpful when tailoring an approach to weight and nutrition counseling. I’ve had many patients who are not yet ready to discuss making dietary changes, even when their calculated BMI puts them in a range that is considered to be at risk for significant health issues. 

For each of the stages, I offer a tailored approach. For the pre-contemplative stage, I’ve found that using non-confrontational and patient-centered motivational interviewing to explore patients’ feelings about weight and health is especially worthwhile. For the contemplation stage, I aim to provide information and support to help the patient balance the pros and cons of change. For the preparation stage, I assist in setting realistic goals and creating a plan of action. For the action stage, I offer practical support and resources for implementing changes. And finally for the maintenance stage, I help the patient develop strategies to sustain long-term changes and prevent relapse.

3) Utilizing Appreciative Inquiry and Coaching Techniques:

Incorporating coaching techniques, such as Appreciative Inquiry (AI), can also significantly enhance our effectiveness in supporting patients’ weight and nutrition goals. AI focuses on strengths and positive experiences rather than problems, which aligns well with a shame-free approach to weight management. I’ve worked with many people who struggle with emotional eating. When we focus on episodes when they’ve chosen to take a walk or breathe mindfully, rather than eating until they are ‘over-full,’ they feel empowered to manage their stress in other ways. Aim to:

1) Ask powerful questions: “What does health mean to you?” or “When do you feel most energized?”

2) Focus on strengths: Help patients identify and leverage their strengths and resources.

3) Co-create solutions: Work with patients to develop strategies for their unique circumstances.

4) Celebrate progress: Acknowledge and reinforce positive changes, no matter how small.

4) Relying on Insights from Preventive Medicine and Lifestyle Medicine:

The fields of preventive medicine and lifestyle medicine offer valuable perspectives and tools for addressing weight and nutrition in clinical practice. These specialties emphasize addressing root causes and promoting overall health rather than focusing solely on weight loss.

Key concepts from these fields include:

1) Emphasize whole-person health: Address sleep, stress, physical activity, and social connections alongside nutrition.

2) Focus on plant-based eating: Encourage a diet rich in fruits, vegetables, whole grains, and legumes.

3) Teach kitchen literacy: Offer resources for meal planning, grocery shopping, and basic cooking skills.

4) Address social determinants of health: Recognize and address barriers to healthy eating, such as food insecurity or lack of access to fresh produce.

Medical practitioners should also strongly consider partnering with other health professionals who have additional credentials and knowledge, such as registered dietitians and board-certified health and wellness coaches. 

5) Correcting Misinformation:

In the age of social media and celebrity-endorsed diets, patients often come to us with misconceptions about nutrition and weight loss. Addressing these myths requires tact and evidence-based information. There are many helpful resources for practitioners, including those available through the American Board of Obesity Medicine. While it is vital to have correct information to provide to patients, simply lecturing them about how they are wrong may backfire and cause them to feel angry, defensive, or ashamed. Instead:

1) Ask open-ended questions: “What have you heard about this diet?” allows you to understand the patient’s perspective.

2) Provide evidence-based information: Share reputable sources and explain the science in accessible terms.

3) Acknowledge the appeal of quick fixes: Validate the desire for rapid results while explaining the benefits of sustainable changes.

4) Offer alternatives: If patients are interested in a fad diet, suggest evidence-based options that address their specific goals.

6) Addressing Weight Loss Medications:

With the increasing popularity of weight loss medications such as GLP-1 agonists, it’s necessary to engage patients in informed discussions about their role in overall health. Medications are tools, not magic solutions: they work best in conjunction with lifestyle changes. They are also not appropriate for everyone. I’ve had several patients with normal BMIs and no other weight-related health concerns request prescriptions for GLP-1 agonists. I’ve also had patients who are not good candidates for medication, even when they may “qualify” based on their risk factors. When I review people’s overall health and discuss the potential side effects, long-term implications, and realistic expectations for weight loss while on GLP-1 agonists, we are usually able to find a path forward that does not include these medications. Patients who do take these medications need long-term support and follow-up. 

7) Leveraging Generative AI (GenAI) in Weight Management:

As we navigate the complexities of weight management in clinical practice, we can turn to the exciting offerings from GenAI. While GenAI will never replace the human touch in health care, it can be a powerful tool to augment our efforts and provide personalized patient support. Using reputable medical information sources such as OpenEvidence, there are many ways that practitioners can put GenAI to use, including:

1) Personalized meal planning: GenAI can generate customized meal plans based on a patient’s dietary preferences, nutritional needs, and health goals.

2) Behavior change prompts: GenAI can send personalized messages to patients, reinforcing healthy habits and providing motivation based on their stage of change.

3) Educational content creation: GenAI can generate tailored nutrition and weight management educational materials, ensuring patients receive information relevant to their specific needs and literacy level.

Before sharing GenAI-created output and resources with patients, practitioners should always take the time to review them thoroughly, as this technology has been known to produce nonsensical or inaccurate “hallucinations” at times. When embracing these technological advancements, it's imperative that we maintain a critical eye and ensure that GenAI tools are evidence-based, ethically developed, and used in a way that complements rather than replaces the vital human elements of medicine. 

As practitioners, we can significantly impact our patients’ relationships with food and their bodies. We can provide more effective and compassionate care by incorporating evidence-based behavior change models, coaching techniques, and principles from preventive and lifestyle medicine. Our goal is not to create “perfect” eaters but to support our patients in nourishing their bodies and minds to enhance their quality of life and reduce their risk of harmful health outcomes. By shifting our focus from weight to overall health, we can create a more effective and empowering approach to nutrition counseling.

How do you broach the topic of weight and nutrition with patients? Share in the comments!

Dr. Lisa Belisle is a family physician and associate chief medical officer with a rural Maine health care system. She loves running the wooded trails on the island where she lives, and boating the nearby waters with her husband and their six grown children. Watch her weekly video podcast on radiomaine.com. Dr. Belisle is a 2023–2024 Doximity Op-Med Fellow.

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