Chewing the fat about fat with clients

This cat is open to, but not necessarily enthused about, an extended discussion and action plan to reduce his weight. (Shutterstock.com)It's no secret that obesity is on the rise among companion animal patients in the United States and abroad.1-7 Up to 50 percent of U.S. pets8-11 are obese. This health status is shared by 22 to 40 percent of pets worldwide.12

As veterinarians, we know that obesity is a common link to systemic disease. The following conditions have been associated with obesity in dogs:1,6,13-20

• Bacteriuria and ascending urinary tract infections or urolithiasis

• Cardiovascular disease

• Diabetes mellitus and insulin resistance

• Lameness and osteoarthritis

In addition, overweight dogs have shorter lifespans, by two years, than their slim counterparts.18,21

As professionals, veterinarians recognize that obesity is a welfare issue, yet we are reluctant to address the figurative and literal elephant in the room.

Research also tells us that our clients are likely to underestimate the body weight of their furred companions.12,13,22-24 Therefore, clients are unlikely to initiate weight-reducing measures without our help.

To combat this growing epidemic, it's critical that we as a profession improve efforts to discuss nutrition and weight status openly. Only then can we acknowledge, clarify and address weight concerns to effect change among the companion animal populations.  

How can you effectively introduce this topic to a consultation without damaging the tripartite veterinary-client-patient relationship? Walk your way through this sample script, with lessons along the way, to see if you can identify the places where you struggle and could change a little bit of your conversations to make a big difference ...

Let's look at Levi …

Consider a clinical scenario in which you've just examined a 4-year-old Labrador, Levi, at his annual wellness visit. At his last visit one year ago, Levi was estimated to be five pounds greater than his ideal body weight. Today, Levi weighs 20 percent more. You're anxious about bringing up his weight gain because you recall that the client wasn't eager to discuss Levi's weight at his last exam.

Big idea: Don't assume that just because weight management was met with resistance before, it's automatically off-the-table as a subject. Use each consultation as a new opportunity to discuss weight-related concerns: “I know we've discussed Darcy's weight in the past. Have you given any thought as to that conversation and how we might be able to work together to create change?”

You: Levi appears to be in good spirits. As we move forward with his exam today, are there any concerns you have about his overall health or well-being?

Client: No, I don't think so. He's been fine.

You: That's great! How is his activity and energy level these days? I remember that last year you said he was like the Energizer Bunny, he just had one speed and it was go, go, go!

Client: I think he's finally starting to settle out of puppyhood. He's not as bouncy as he used to be.

You: Yes, perhaps he's learning what it's like to be an adult. I also can't help but notice that Levi has gained a significant amount of weight since last year. Have you?

Client: Oh, I don't know, he's not that bad.

Big idea: If you feel resistance, don't hide from it. Identify and acknowledge your client's non-verbal cues: “It feels to me as if you're closed off to this conversation.” … “I sense that you're uncomfortable about this discussion. Help me to understand where you are coming from and what I can do to put you more at ease.”

You:(speaking to Levi) What do you think, Levi? I see that you're getting quite the belly there. (speaking to the client) I am concerned that Levi has put on a significant amount of weight. Levi weighed 75 pounds at his last visit. He's now 90 pounds.

Client: He had some filling out to do since last year.

You:(speaking to Levi) I think you overshot your goal, Levi. (speaking to the client) What are your thoughts about his current weight?

Big idea: Engage in dialogue with the patient concerning difficult topics: “Darcy, it's time that you and I had a little chat about your weight … "

Client: Well, now that you mention it …

You: Do you think there's room for some improvement?

Big idea: Elicit your client's perspective: “Tell me your thoughts about Darcy's weight.” … “Are there activities that Darcy used to enjoy that she no longer seems able to? Why might you think that is?” … “What are some barriers that might prevent Darcy from losing weight?” … “What are you most concerned about?”

Client: I suppose … it's just that he really likes to eat, and it's hard not to give in.

You: Absolutely it is hard! I know! I struggle with the same issue with my own dog. They've all got “The Look.” Do you know what I mean?

Big idea: Acknowledge that weight management is a challenging journey, and that it is a marathon, not a sprint: “You're not alone. I sometimes struggle with … ”

Client: Yes! Levi has mastered it. It's so much easier to just give in.

You: For sure! But what Levi doesn't know is that if he continues to gain at this same rate, his body can't keep up. May I share with you some of the other problems that obesity may cause as he ages?

Client: OK.

You: Obesity is very hard on Levi's joints. In fact, it may be one of the reasons he's less active than normal. But joints aren't the only body part that we worry about …

[Start a conversation about obesity and its link to systemic illness]

Big idea: Assess your client's knowledge about obesity in companion animals: “Did you know that weight gain could contribute to Darcy's arthritis and make it more challenging for her to get around?” … “Did you know that just carrying around a few extra pounds can shorten Darcy's life?”

Client: So you're saying Levi won't live as long if he's overweight?

You: Yes. On average, obese dogs have shorter lives than dogs that are healthy body weights.

Client: But he seems so happy.

You: Yes, he is. For now. But he won't be happy if his joints start to hurt. And it won't be easy on you if he becomes diabetic and we need to manage that. Investing in the hard work now may save us from problems later.

Client: I tried to cut back on food, but it didn't work.

You: That's a good start. It isn't easy. I get that. Can you walk me through what specifically you've tried to do?

Client: I reduced how much I fed him from one scoop twice a day to three-quarters of a scoop, twice a day.  

You: I see. Is there a way for us to measure out how much food is in three-quarters of a scoop?

Client: I have a gram scale at home. I suppose I could weigh it out. Would that help?

You: Yes, it would. With your permission, I'd like to calculate how much he should be eating a day, compared to how much he's eating now.

Client: OK.

You: To do that, I'm going to need a little bit more information. Can you tell me everything that you feed Levi from the time he gets up to the time he goes to bed?

Big idea: Take a thorough dietary history by using open-ended phrases to encourage the client to share details. Also take the time to understand the client's schedule, time constraints, and potential barriers to weight management by using open-ended questions to clarify daily routines: “Take me through a day in your life: share with me what mealtime is like in your household and how everyone, including Darcy, is fed.” 

[Start a conversation about food intake, including snacks, followed by recommendations for how to move forward]

You: I appreciate your willingness to work together to get Levi back on track. I know it won't be easy, but we're in this together.

[Result: The veterinarian contracts for the next steps, to which the client agrees. The client calls back in the next few days to share the exact quantity of food fed at each mealtime. The veterinarian uses this to develop a feeding schedule with restricted caloric intake and provides recommendations for increasing Levi's activity level. The client commits to returning for bimonthly weigh-ins.]

Big idea: Check in with the client so that you both are on the same page: “What's your ultimate goal concerning Darcy's weight?” … “What should we be working towards?”

‘Oh please. It's NEVER that easy'

I get it. Although this conversation represents the best possible outcome for Levi, recognize that weight management plans may take time to obtain client buy-in. It could take several planned discussions before a pet owner is willing to consider weight loss as a feasible goal. It could take several more conversations before the client is spurred into action.

Don't accept the pet's weight loss as your only success. You need to consider that success takes many different forms. The first step towards success is simply getting the client to acknowledge that obesity is a problem. This requires patience and the ability to trade hats with clients to see their point of view. Clients need to feel safe to share their perspective, and they benefit from support throughout the weight-loss journey.

Big idea: Celebrate small changes in the right direction, and use small victories to set new goals: “You've worked really hard to get that half-pound off Darcy. Great job! Now that we've managed to get Darcy down by a half pound, let's consider what it will take to get her to lose a full pound.”

The fact that weight loss isn't an instant outcome works against the process. Your own committed and motivating attitude is often the first step towards a mutually agreeable solution.

References

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Ryane E. Englar, DVM, DABVP (canine and feline practice), is an assistant professor and clinical education coordinator for Kansas State University College of Veterinary Medicine in Manhattan, Kansas. Her teaching responsibilities include designing and debuting a new Clinical Skills curriculum for veterinary students to improve their confidence and competence with professional and technical skills. Her research emphasizes veterinary client communication preferences. You can reach her at renglar@vet.k-state.edu.