By Lori A. Burkhart, J.D.
SCREENING PATIENTS FOR OBESITY is part of the overall wellness paradigm for which doctors of chiropractic (DCs) are well respected. But discussing obesity is a subject fraught with unexpected danger for the doctor and the patient. Balancing health concerns with the often fragile psyche of the overweight patient is an important concept to handle correctly.
In a 2008 article1 by Daniel Redwood, DC, he quotes Harvard University medical school professors, Kaptchuk and Eisenberg, who describe appreciatively the relationship DCs often have with patients: “The ability of chiropractors to develop rapport and connection with their patients is among the greatest strengths of the profession.”
In 2010, Kathleen Sebelius, secretary of the U.S. Department of Health and Human Services, submitted a report to Congress on “Demonstration of Coverage of Chiropractic Services Under Medicare.” This report notes, “Sixty percent of respondents indicated that they received ‘complete’ or ‘a lot’ of relief of symptoms from their chiropractic treatments. Satisfaction with care was high, with 87 percent reporting levels of 8 or higher on a 10-point scale and 56 percent indicating a perfect score of 10. Similarly high proportions reported that chiropractors listened carefully and spent sufficient time with them.”2
Chiropractic research via a consensus process aimed at developing a best practice document on chiropractic’s role in health promotion demonstrates that DCs should screen patients for obesity (by obtaining a body mass index), physical inactivity, tobacco use and hypertension. They should counsel individuals with risk factors on tobacco cessation, physical activity, weight management and healthy diet.3 Also, “Chiropractic care provided for the purpose of preventing disease, optimizing function and supporting the patient’s wellness-related activities is best termed wellness care, although the term preventive care may also be appropriate.”3
How to Proceed
It’s important for chiropractic physicians to use their successful patient relationships to discuss wellness or preventive care with patients. But with weight being a difficult subject for the doctor and patient to broach, how best should you proceed?
Set the stage, according to Scott Bautch, DC, DACBOH, an ACA spokesman and chairman of the board and CEO for Allied Health Chiropractic Centers in Wisconsin. He says he first lets his patients know he is a total health doctor. “I gently ask my patients outside of the back pain if there are subjects they would like to address,” he explains. “I include posture and exercise, but I typically will not introduce the word ‘weight,’ and instead I use the phrase ‘healthy life plan.’” Dr. Bautch prefers that patients bring up concerns about their weight. “The patient may say something such as, ‘I continue to struggle,’ which might be my starting point.” He explains how important it is not to blindside people, noting he made that mistake early in practice. He waits for an opening. After all, he continues, “Do you think there’s anybody who is overweight who doesn’t know they are overweight?”
First, get permission to talk about weight, advises Dr. Bautch. “The starting point may be something like ‘I just don’t have discipline to follow through,’ and so how can you help them through the stages of change such as pre-contemplation, contemplation and information? That is giving the information at a point that makes a patient want to take an action step,” he says. But he cautions that jumping in at the wrong time will make the patient rebel.
Use caution, agrees Deanna K. Bates, DC, DAAPM, FICC, who owns a practice in Chesterfield, Mo., and teaches at Logan University. “I don’t ask about weight, particularly if I sense they may be resistant,” says Dr. Bates. “I usually wait until I establish some level of rapport and trust before delving very far into this area with newer patients. They may then be more receptive.” She also finds it important to come from a place of caring and not judgment. “I recently had a patient who has been obese all her life tell me that I am the only doctor who hasn’t told her she needs to lose weight,” she says. “I prefer to ask about a patient’s feeling of health and well-being: ‘How is your energy?’ ‘How do you feel about your health’ ‘Any concerns?’ ‘Any goals?’ ‘What activities and exercise do you enjoy?’” Dr. Bates prefers to focus on getting patients feeling better in order to enjoy activities and life. “Often, a patient will bring up the subject, which makes it easy to open a conversation about weight,” she says.
Discussing Diet and Nutrition
In order to be leaders in wellness, chiropractic physicians are taking aim at issues surrounding diet and nutrition. According to Dr. Bates, weight and therefore issues of general health and wellbeing could influence virtually any issue for which a patient might consult a chiropractic physician. But when a patient has an obvious weight problem, Dr. Bates adds, “Clues to endocrine or poor dietary and activity habits can help us help patients heal more readily and improve their overall health. We may be the first to discover diabetes or a thyroid or other endocrine/metabolic issue, which can lead to obesity and also slow healing time and result in poor general health and well-being.”
Dr. Bates finds it important to check on the blood sugar levels and thyroid levels, taking a much closer look at the so-called “normal” range (i.e., typically the lab’s reference range using two standard deviations (SD) from the mean, which translates to about 96 percent of that lab’s test population). “If patients are not in the middle or one SD from the mean, I look closely at diet and lifestyle factors, which may indicate a prediabetic state and/or hypothyroidism, etcetera.” she says. “I then may supplement, encourage dietary modifications or make a referral.”
There are so many reasons why people become obese in this country, says Dr. Bautch, taking aim at our nation’s food industry. He uses malfeasance by the food industry to help take the pressure off his patients. “Society often says, ‘well, if you just eat less and exercise more you would lose weight.’ Sure, that’s why so many in our society are overweight,” he quips. He notes overweight people tend to be self-conscious. “In my clinic, we try to broach educational opportunities every chance we can via magazines, wall posters and handouts. Our staff is creating a comfortable and safe environment all the time so that patients feel they can bring sensitive issues up to us.”
Overcoming Patient Resistance
When a discussion on obesity is needed – for example, when a test raises concerns – but the DC expects some resistance, what is the best path to take? Consider these ways to educate patients without talking directly about weight. Dr. Bates says she encourages exercise and enjoyable activities. “I often ask patients what they typically eat for breakfast, lunch or supper and find ways to encourage healthy and anti-inflammatory food choices.” She asks if patients have any digestive problems because sometimes people eat too fast and therefore too much and can’t digest well. Or breakfast may be carbohydrate-loaded so they get hunger pangs in an hour or two. “Above all, I like to be sure they are drinking plenty of water,” she says.
Psychological barriers and high stress levels are also sometimes found in overweight patients, according to Dr. Bates, which must be addressed before a patient can become healthy. “In these instances, I may offer to refer for stress management counseling/coaching,” she says.
Overall, Dr. Bates encourages patients to accept themselves as they are, pointing out that we all come in different shapes and sizes. “Just focus on feeling good and being healthy,” she advises. “Be okay with who you are now – don’t hate and fight against yourself. You and yourself need to be on the same side in order to get well.”
The best path depends on the degree of obesity, according to Dr. Bautch. “There are certain times in life, usually between the ages of 25 and 35, when a patient realizes he or she just gained some weight,” he says. “Perhaps a woman just had a baby, or someone with a first job has been working too much. In that age range, they want to talk about getting in shape and usually will just ask.”
Dr. Bautch finds patients who are mildly obese to obese are difficult to engage in conversation. He attributes it to so much social damage that has occurred. He uses the example of an obese patient much too large for his X-ray machine. “I tried to be very delicate about the issue, but she called me later just sobbing and feeling horrible because I had made her feel bad about her weight,” he says. “I learned my lesson.”
“My goal is to coach someone in a healthy way every way I can,” explains Dr. Bautch. He presented the aforementioned patient with an increased activity plan. “In Wisconsin, when it’s 10 degrees below zero, I start with a winter movement plan,” he says.
Dr. Bautch advises becoming comfortable with, and understanding, the phases of change. “Understand that everybody wants to be healthy, and nobody wants to be injured,” he says. As a president of ACA’s Council on Occupational Health, he looks at stages of change and behavioral-based safety, which means being aware of the strength and capabilities of that person, not what is wrong with them.
“So if I’m going to get somebody to change, I’m going to have to find what are they really good at. If somebody says to me, ‘I used to drink 12 cans of Mountain Dew a day, but now I’m drinking only 11 cans a day,’ you have to make a big deal of those small wins,” Dr. Bautch explains. “Because when someone loses five pounds and still has 95 more pounds to go, realize we get 17 negative messages in society for every one positive message. Barbara Fredrickson in her landmark work, Positivity, says we need three positive messages for every one negative message given to us to survive, and seven to one to thrive.”
According to Dr. Bautch, obese people are already beat up and struggling to change, or they would just do it. He advises finding small wins and really complimenting patients. “If you advise patients to walk extra steps, simply ask how it went and give a high five and say thanks for caring enough to take control,” he says. “You have to really understand stages of change, the human dynamic, the movement toward strength-based changing, not problem-based changing,” he says.
1) Redwood D, Globe G. Prevention and Health Promotion by Chiropractors. American J Lifestyle Med 2008; 2; 537.
2) Stason WB, Ritter D, Shepard DS, et al. Report to Congress on the Evaluation of the Demonstration of Coverage for Chiropractic Services Under Medicare. Baltimore: Centers for Medicare and Medicaid Services; 2009.
3) Hawk C, Schneider M, Evans Jr. MW, Redwood D. Consensus process to develop a best practice document on the role of chiropractic care in health promotion, disease prevention and wellness. J Manipulative Physiol Ther. Sep 2012;35(7):556-567.