Weighing patients by default?

[rev ronin]

As most of you know, I've been treating eating disorders patients for the last couple of years.  About once every month or two, we have to pick up the pieces when one of our patients goes to an outside specialist and gets weighed.  I wrote a reflection piece for JAAPA (accepted late last year, publication TBD) describing a couple of them.  But if anything has changed in me as I get older, it's an appreciation that my perspectives, as much as they may uncover harms, may also blind me to benefits outside my own sphere of influence.

So, with that as background...

Does anyone in primary or outpatient specialty care who routinely weighs patients (unless they forcefully object) and puts the weight and/or BMI on the after-visit summary ever notice any good coming from that practice?  I mean, other than the fact that you get more money for "meaningful use" stage 3 criteria, that is.

Seriously, does it really benefit anyone, anywhere?

[sas5814]

It is a valuable point of discussion if you are really their PCP and making a legit effort to help them manage their lifestyle and make changes. It also has some value in patient with, for instance, CHF. I have occasionally found their control of their illness slipping before the patient realized it. So it has a place.

In the ER or UC? Meh.... no value

People with eating disorders are in a unique class and require special consideration and handling. Sometime as PCP we don't find out about an eating disorder until way down the road. 

[rev ronin]

3 hours ago, sas5814 said:

It is a valuable point of discussion if you are really their PCP and making a legit effort to help them manage their lifestyle and make changes. It also has some value in patient with, for instance, CHF. I have occasionally found their control of their illness slipping before the patient realized it. So it has a place.

In the ER or UC? Meh.... no value

People with eating disorders are in a unique class and require special consideration and handling. Sometime as PCP we don't find out about an eating disorder until way down the road. 

Definitely understand for CHF'ers.  THAT makes sense.

Not so sure about the basic metabolic syndrome American... If the PCP does find weight trending up, how often is meaningful advice given? And by that, I mean something more than "try the Mediterranean diet and get 150 minutes of moderate exercise per week" and maybe a non-personalized handout.

About the ED folks... they may be a unique class, but when you add up AN, BN, BED, and OSFED together, you're looking at possibly 5% prevalence.  The vast majority of these patients do not look cachectic--that's only the poorly controlled anorexics.  Most everyone else looks like a "normal" American, thin to morbidly obese. And yet, how many primary care clinicians actively screen for eating disorders?

[Arthropathy]

Working in a surgical sociality weight and BMI play a role in assessing risks of wound healing, infection, and hardware failure. But mostly it's for meaningful use.

[rev ronin]

1 hour ago, Arthropathy said:

Working in a surgical sociality weight and BMI play a role in assessing risks of wound healing, infection, and hardware failure. But mostly it's for meaningful use.

In my pain management practice, I see perhaps 25% of my obese patients have been told by surgeons to lose weight before a knee or hip replacement, or perhaps back surgery, is conducted. It's an interesting dilemma--while there's no question that heavier patients are more at risk of such complications, what is uncertain is whether many of these folks are able, without structured help, to attain the desired pre-surgery weight.

Weight loss is intricately connected with eating disorders, of course, but unfortunately obesity is generally treated as a moral failure, a disease in itself, or both, when in fact it's actually a symptom of something else going on.  Such prejudice against the overweight, is rampant in the medical system, and while there's no doubt good cause to reject overweight surgical patients, given the level of disgust and revulsion expressed by society at large and in the medical community, I wonder if that is truly the whole story in every practice.  Rather, I suspect it is not.

Oh, and obviously anesthesia needs weights for anyone being sedated. That is clearly an appropriate medical use for weight.

[thinkertdm]

 

Its a handy tool, to trend their weights dropping- over the course of a year, you can watch a subtle neoplasm at work, rather than relying on subjective symptoms which people either minimize or exaggerate.  Or I’ve had a couple with a weight gain of ten pounds or so- not so much they noticed it, but enough to make me wonder if they might have some fluid overload developing.  They didn’t notice the dyspnea because their lives were pretty sedentary .

Also in the reverse- for the people with “leg swelling” I use the weight to get an idea of what their body is doing.  Most of the time it’s because of dependency on sodium and gravity and not kidneys or their heart.  Not my only metric, but a clue.

[CAAdmission]

If you don't want to check weights on someone with an eating disorder, that's a valid decision. But weight is a body metric directly associated with health problems. It's neglect to not check it for fear of causing someone discomfort. You know what else causes discomfort? Bypass surgery.

This "fat shaming" nonsense has got to stop. People are fat due to an calorie intake/expenditure imbalance. They don't photosynthesize weight. Fat people are not bad people, but they need to own their problem and not to try to normalize it. 

Disclosure: I am speaking as a relatively fat slob myself. It's my fault I'm fat.

[ANESMCR]

I monitor weight pretty frequently, in outpatient GI. 

[ventana]

straight PCP here

I advocate for it every visit - ongoing issue with my 30yr MA who thinks it is a suggestion

 

Yes it is used and I think it holds weight to have a trend

Metabolic syndrome, PCOS, CAD, DM all get worse with weight, my job is to bring up the obvious to the patient, and explain the benefits of healthy weight - no way to know what that is with out the data....

 

case in point, nice middle aged female, MH hx,new meds, thinks she gained a little weight, says she might be 200  My MA did not weigh her the last two visits - I put her on scale and she is 248, BMI almost 40, BS elevated, HgA1C 6.4

DM Dx, now a who lot more complex

 

Even for myself my weight in the yearly (or every few years) is something I pay attention to...

 

For what it is worth - my practice have NEVER done any meaningless use measures or pay.....  we take a little hit, but it is worth it to not chase the stupidness of it....

[rev ronin]

4 hours ago, CJAadmission said:

If you don't want to check weights on someone with an eating disorder, that's a valid decision. But weight is a body metric directly associated with health problems. It's neglect to not check it for fear of causing someone discomfort. You know what else causes discomfort? Bypass surgery.

This "fat shaming" nonsense has got to stop. People are fat due to an calorie intake/expenditure imbalance. They don't photosynthesize weight. Fat people are not bad people, but they need to own their problem and not to try to normalize it. 

Disclosure: I am speaking as a relatively fat slob myself. It's my fault I'm fat.

So how do you tell if someone has an eating disorder?  Can you identify the 5% of your panel who do?

I get that you don't have a life-threatening mental health disorder tied to your weight; I don't either.  I just see the aftermath of PCPs, specialists, and MAs who blithely prattle on about weight in the most insensitive manner without bothering to ASK first. Is it appropriate for me to prattle on about the new microbrew I'm experimenting with if I haven't assessed whether my patient has a history of alcohol use disorder? Same thing.  We have plenty of easy-to-use screening tools for eating disorders, but use and adoption is, in my opinion and observation, lagging compared to the prevalence of eating disorders in our patient population.

NOTHING we do is perfectly benign, and that's my point. Even the simple act of weighing the patient "open" and showing the patient his or her own weight can cause formerly managed eating disordered behavior to reemerge. Calling it 'discomfort' minimizes the mental illness underlying that reaction, and the morbidity and mortality associated with eating disorders.

So weighing the patient is a risk analysis: does it benefit more than it harm?  That's the premise I started with here, and I have had one unequivocally clear (my judgment, of course, yours or anyone else can differ) case of benefit greater than harm, and that's with CHF.  The other issues about weight trending and assessing the risk of surgical complications... I'd call those arguable. I really don't know whether the benefits outweighs the risk or not.

But we need to have this conversation, not just kowtow to Meaningful Use as if it were by definition normative.  Our professional ethical obligation to non-maleficence does not and should not factor in government mandates.

[sas5814]

17 minutes ago, rev ronin said:

So weighing the patient is a risk analysis: does it benefit more than it harm?

This dovetails into one of my mantras..... if the test isn't going to change the treatment..why do the test?

Weighing someone should be decided by the same metric. Is it going to change what you do? What is the diagnostic yield? Sure if you xray every chest every year you'll find some surprises but is the cost both financially and to the patient getting a useful yield? That is how screening recommendations are determined. Why not vitals and weight?

[CAAdmission]

1 hour ago, rev ronin said:

So how do you tell if someone has an eating disorder?  Can you identify the 5% of your panel who do?

That's well said, and will probably trigger me to screen more aggressively for these folks. 

In terms of public health and bang for the buck, it still makes more sense to focus on the other 95% of my patients. They have a modifiable risk factor for our biggest killers, heart disease and cancer. There is a concerted effort going on right now to make obesity "normal" or a "lifestyle choice" like getting a piercing or a tattoo. (I linked an article to this effect over in the politically incorrect forum.) It's not as simple as that.

These people are putting an unnecessary strain on our healthcare system and consuming a disproportionate share of healthcare dollars. Now that the Affordable Care Act penalty somehow got tacked onto our taxes, we could also create a BMI penalty that could pay into the insurance pool to pay for care for these people. Same with smokers. 

[sas5814]

I have seen some employers that had a sliding scale rate for the employees health insurance based on their risk factors. It wasn't popular but it sure did get a lot of people in my office asking about tobacco cessation and weight loss.

[iconic]

How can you tell how severe an eating disorder is without weighting someone? Especially since anorexia is literally tied to BMI

[rev ronin]

52 minutes ago, iconic said:

How can you tell how severe an eating disorder is without weighting someone? Especially since anorexia is literally tied to BMI

Excellent question!  First off, Anorexia diagnosis has evolved over the years.  It used to be impossible to diagnose anorexia nervosa in males because amenorrhea was a mandatory criteria!  Eating disorders are really more of a tripartate spectrum--restricting, binging, and purging, in different ratios and amounts, denote a number of different eating disorders with separate criteria.

About half of the "anorexics" I treat are not properly diagnosed as AN, but rather atypical anorexia nervosa which is a subset of OSFED.  Think about this: If the patient is 5'2" and loses weight from 200 to 150 over the course of a few months, what is their nutrition status going to look like?  They're starved, just as surely as if they had a BMI in the mid teens as a "classic" anorexic would, because the restriction and [maybe] purging (usually via exercise, but could be via self-induced vomiting, laxative abuse, or other means) has trashed their nutritional stores.  BUT, since their weight is still average or above... they don't have diagnosable anorexia yet.  Hence, OSFED/Atypical AN.  These are the folks we WANT to see in treatment, because the earlier an eating disorder is identified, the easier it is to treat.

For primary care screening, I'd use SCOFF.  I'd call it an equivalent to CAGE or the PHQ-2/9.

https://www.verywellmind.com/the-scoff-questionnaire-1138316

The EAT-26 is heavier lifting if SCOFF or history suggests a more deep dive is needed, but there are other tools, too, and I would say the important thing is to do the prelim screening and refer for a formal eval if you don't feel comfortable doing more than that in primary care/UC/ED/Women's health.

https://pubmed.ncbi.nlm.nih.gov/16432540/

 

Edited March 31, 2021 by rev ronin

[ohiovolffemtp]

From the EM point of view, enough of the IV meds I use for critical patients have weight based dosing, that we do try to weigh, or at least get recent weights, for them.  Think insulin, some abx (also have to think about creatinine clearance), heparin, etc.  It's also relevant in the CHFer's, the (non compliant) dialysis patients, ....

Rev, is the weighing of the patient the main trigger of the problem, or the discussion of the weight done without proper consideration of the impact of that discussion on the patient the problem?  I'm more likely to ask about recent significant weight changes.

[rev ronin]

1 hour ago, ohiovolffemtp said:

Rev, is the weighing of the patient the main trigger of the problem, or the discussion of the weight done without proper consideration of the impact of that discussion on the patient the problem?  I'm more likely to ask about recent significant weight changes.

It's almost never the weighing itself, although that is a stressor, but rather 1) knowing the weight, or 2) hearing weight, exercise, or diet advice that mimics or rejects strongly held beliefs.

I can think of almost no instance where a patient NEEDS to know his or her own weight, even if the medical professional does.  Certainly, weighing might be offered to a patient, and the knowledge of what that weight is would be offered as well.

I've had binge eating disorder, bulimic, and anorexic patients told their weight, even when they or my clinic had told the practice in advance that these patients were under active eating disorders treatment and we would manage their weight, diet, and exercise, thankyouverymuch. I've had a bulimic patient who purged by excessive exercise recommended basic generic diet and exercise advice on a new PCP visit with an NP.  The generic advice would be fine if there was some sort of screening done beforehand to make sure it was, you know, actually appropriate.  Why do we contact practices in advance? Because the patients asked us to do so on their behalf, so they don't have to talk about it with strangers who aren't part of their treatment team. Eating disorders are generally invisible (you may see the effects, but mostly in late disease unless you check for Russell's sign on everyone) and involve a lot of shame. So no, these patients are sometimes not really willing to advocate for themselves, so we do it for them.

I get to pick up the pieces (well, me and the RD's, therapists, program assistants, and psychiatrists who make up the team) seriously every month or two, which is stupid, because we only have maybe 4-6 new patients a month.  I've seen relapse into cutting, binging, restriction, suicidal ideation... This isn't just someone getting their feelings hurt, these are mentally ill people in (semi-, usually) recovery from a very risky illness diving right back into the same behaviors that can kill them.  I'd guess it averages about a two week treatment setback when a patient is subjected to a distressing comment or suggestion from a medical provider.