Case Scenario

I work in a busy office where our relationships are cordial. Recently, a member of our office staff has been putting on quite a bit of weight. Already heavy, she has gained what I estimate to be 50 lb (22.7 kg). She has been having some personal problems at home, but in the office she is efficient, competent, and reliable. My colleagues have been talking about whether it is our job as physicians to talk with her about her weight and the possible health problems it could cause. I am not sure it is any of our business. We are strictly professional in our interactions and, except for a staff picnic, do not socialize outside of the office. Still, we know a bit about each other's lives. Is it our responsibility to talk to this staff member about her weight even if her unhealthy behaviors are not affecting her work performance? Does it make a difference that we are physicians?

Commentary

This case scenario addresses important and commonly encountered medical problems: weight gain and obesity. The rates of overweight and obesity have increased dramatically. According to the latest estimates, more than 34 percent of U.S. adults are obese (body mass index [BMI] of at least 30 kg per m²).¹ The impact of weight gain and obesity on comorbidities is well known, especially on the risk of developing diabetes mellitus, cardiovascular diseases, and cancer. Those comorbidities affect health care costs. Physicians are generally comfortable discussing weight and lifestyle factors with their patients. However, it becomes tricky when addressing these issues with an employee.

The physician–patient relationship is different from the physician–employee relationship. It is appropriate to consult with an employee about health concerns in an emergency situation, but many physicians will not provide consultations for chronic care. It can be a challenge to serve as a patient advocate and as a boss. You have the right to expect top performance from your employee, but you cannot make weight a criterion for a performance evaluation. Still, the health status of office employees should not be ignored. When we work together on a daily basis, we grow to respect and care for each other.

The following guidelines walk the primary care physician through an encounter with an employee about weight, and offer direction on how to navigate the subject to the benefit of the employee and the office.

Examine your motives. Our culture values thinness and at times can be overly concerned with weight as a cosmetic issue. People are very sensitive about their weight, and this holds true for men and women. Being overweight or obese carries a stigma, and you must tread carefully. Your employee may perceive a negative value judgment on your part when you raise the issue of weight. Examine your motives; are you worried about how your employee looks, or are you genuinely concerned about her health and well-being?

Introduce the subject. Weight loss is a sensitive subject. The conversation should be private and delivered by you or another health care professional, preferably one who has some training in behavior psychology. The discussion should not be linked to a performance appraisal or job review. As a physician, you should emphasize health concerns, not appearances. Focus on behaviors that promote success. You should avoid the terms obesity and overweight.

Begin with a positive statement. Validate the employee's contribution to the practice. For example, “You've worked here for six years, and your contribution to our practice is valued. You are a great team player, and we can count on you.”

Acknowledge your sensitivity to the issue, and ask permission to continue. Let the employee know that you are concerned for her health, and that you recognize this is a delicate subject: “I want to raise an issue that is somewhat difficult for me. I am concerned about your health and worry that you are not practicing healthy behaviors. Several of us have noticed some recent weight gain and we are concerned. Is it okay if we talk about this for a few minutes?”

Respect your employee's space, but leave the door open for future discussion. If your employee does not want to talk, she may be in what behavior psychologists call the pre-contemplation stage,² and she will not be responsive to intervention. However, you have an opportunity to encourage and motivate. Express your concern for her health, and reiterate that you are available to discuss lifestyle changes. You can also tell her that you will check with her in a few months to see if she wants to talk.

Be prepared to help. If your employee shows interest in losing weight, you should explain the concept of a baseline assessment and devise a plan based on that assessment. Encourage her to schedule an annual wellness evaluation with her primary care physician. Based on the results of her risk factors, her doctor can help determine the next steps. If the patient has prediabetes, many insurers are beginning to reimburse for programs that provide multiple counseling sessions. Otherwise, a self-help approach may be in order. All family physicians should have a list of available resources to support successful weight loss. Referral to a community or commercial program can be helpful. You should make sure that the program employs the proven elements of success: self-monitoring (e.g., weigh-ins, food and activity diaries), behavior goal setting, stimulus control, and social support. Frequency of contact with the program counselor appears to be an important element of success.

Define success. The current guidelines for diagnosing overweight and obesity in adults define normal weight as a BMI of 18.5 to 24.9 kg per m^2.3 In today's environment, even under the best of circumstances, it is not possible for all persons to achieve a body weight that qualifies as a normal BMI. We know that lifestyle changes can reliably produce weight loss of 5 to 10 percent from baseline.^4–6 Losing even modest amounts of weight and practicing behaviors that sustain weight loss can lower patients' risk of diabetes and cardiovascular disease.^4–6 Therefore, even though your employee may still be overweight or obese after a weight loss program that results in a 5 to 10 percent loss from baseline weight, there are still important benefits that may have been gained.

Physician, heal thyself. If your employee does embark on a weight loss effort with counseling for weight management, will your work environment support it? Will your insurer reimburse for counseling in an ongoing weight management program? Does your office schedule promote a healthy work–life balance? Regular physical activity is the single best predictor of long-term weight loss success. Does your office encourage this? Do your office celebrations and parties provide healthy food options? Are other employees encouraging and supportive? Do you have subscriptions to healthy lifestyle magazines available in the office?

It is not an easy or casual undertaking to confront an employee about weight struggles. If you proceed with care and sensitivity, it can have a positive outcome, provided that you have thought through the potential outcomes in advance.