Some of the most-frequent and most-delicate conversations in primary-care doctors' offices involve weight. In modern medicine, there's a push to monitor patients' body-mass indexes and to talk about being overweight or obese and the links to health problems, including Type 2 diabetes and heart disease. Weight as a risk factor is widely accepted, but figuring out the most-productive way to talk about it (or deeming it off the table, as in Howell's case) can be tricky and depends on how a patient views his or her weight.

Peggy Howell and her physician have an agreement. They don�t talk about weight loss. Howell, who regularly calls herself fat, doesn�t want to lose weight.

"I�m of a large body size, and I�m of good health,� she said. �If you want to talk about my (dietary) intake based on resolving a health issue, then I�m all for it."

Howell, 67, lives in Las Vegas and is director of public relations for the National Association to Advance Fat Acceptance.

"I think that it�s important to be informed, but if that is done in a way to make people feel bad about themselves or uncomfortable about themselves, then no,� she said.

Some of the most-frequent and most-delicate conversations in primary-care doctors� offices involve weight. In modern medicine, there�s a push to monitor patients� body-mass indexes and to talk about being overweight or obese and the links to health problems, including Type 2 diabetes and heart disease. Weight as a risk factor is widely accepted, but figuring out the most-productive way to talk about it (or deeming it off the table, as in Howell�s case) can be tricky and depends on how a patient views his or her weight.

Today�s medical education places a high importance on training doctors for the less-comfortable conversations, said Dr. Nanette Lacuesta, the assistant director of the family-medicine residency program at OhioHealth Riverside Methodist Hospital.

Lacuesta said practicing for tough talks makes for smoother real-life scenarios. She has found � and tells new doctors � that open-ended questions work well. An example: �How do you feel about your weight?�

�Then we try to get them to tell us what they�re willing to do,� she said. �Hopefully, you already laid the groundwork that you have their best interest in mind.�

Prescriptive (and often generic) advice � �You need to lose 40 pounds,� �You need to stop eating unhealthy food,� �You have to exercise� � tends to not do patients much good.

She also suggested that patients who want their doctor�s help with losing weight make an appointment dedicated to that. Often, the subject comes up at the end of another visit, and there isn�t time to adequately offer help, Lacuesta said.

�The most-important thing is that it�s patient-centered,� Lacuesta said. �My inclination is to connect it with the health risks such as diabetes, hypertension and stroke. You have to think, � What is going to make it important to them?�??�

Dr. Larry Swanner, a family-medicine specialist and vice president of medical affairs at Mount Carmel West hospital, said the nature of weight conversations varies greatly depending on the physician and the patient.

�Some people don�t want to talk about it unless it�s absolutely necessary,� he said. �Society sometimes makes people feel like failures, like they have a deficiency of character or can�t resist temptation, and that�s not it.�

Swanner said the conversations should happen for the sake of good preventive medicine, but they must come with compassion and empathy. �It doesn�t do any good to shake your finger at them and tell them they�ve got to do better.�

Aside from the fear of offending patients, some doctors avoid conversations about weight because they feel ill-equipped to offer constructive guidance on how to help.

�There�s no one clear, sure-fire cure for this problem. It�s not an easy problem to address,� Swanner said.

Dr. Randy Wexler, a family-medicine specialist with Ohio State University�s Wexner Medical Center, said an increasing emphasis on patient satisfaction in health care can make it even less-desirable to step into conversations that doctors know might be volatile, Wexler said.

�Patients sometimes get upset when we bring up things like that. I�ve had a patient demand to have obesity removed from their chart,� he said. �It doesn�t take many of them to make you gun-shy.�

When he does bring up weight, it�s not on a first visit. He waits until he feels that he has established good rapport and usually looks for an opening, such as mobility problems or high cholesterol.

Howell�s organization has developed guidelines for doctors. For example, it doesn�t want physicians to automatically weigh patients without a compelling reason, it wants them to avoid the word obese, and it doesn�t want them to assume that patients are interested in weight loss.

Howell said she has fielded calls from many people who have been turned away by doctors who don�t want to treat them or would not address their medical concerns beyond assuming that weight loss was the only option.

Lacuesta, of OhioHealth, can see why that could be upsetting. �If I was a patient that was overweight, I can imagine how frustrating it would be to walk in and have your physician assume your weight is responsible for everything that�s going wrong with you,� she said.

mcrane@dispatch.com

@MistiCrane