Tips for treating high-weight patients [PODCAST]

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“It might seem odd to write about what high-weight patients would like when they meet with their doctors. Don’t they want what every patient wants? The answer is yes, but the fact is, they often don’t get it due to implicit anti-fat bias among health professionals.

In my 30-plus years of practice as an eating disorders therapist, I’ve heard the same laments from high-weight clients: Doctors only want to talk about weight, blame every health problem on being large-sized, always want to put them on a weight-loss diet, and advise them to get out and exercise. Clients know from experience at varying weights that they’re treated differently when they’re thinner from when they’re fatter.”

Karen R. Koenig is an eating disorder therapist. She can be reached at her self-titled site, Karen R. Koenig.

She shares her story and discusses her KevinMD article, “5 tips for treating high-weight patients.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow. On today’s show, we have Karen Koenig. She is an eating disorder therapist. Her KevinMD article is titled “5 tips for treating high-weight patients.” Karen, welcome to the show.

Karen R. Koenig: Thank you for having me.

Kevin Pho: We’ll get into your article in a little bit. First off, briefly share your story and journey to where you are today.

Karen R. Koenig: Oh, and professionally, I’m an eating disorders therapist because for half a lifetime, and I’m 75, I’ve been recovered from binge-eating disorder and chronic dieting, which is also an eating disorder. I’m a clinical social worker, and I also have a master’s in education.

Kevin Pho: All right, so tell me about the role of psychotherapy when it comes to treating eating disorders.

Karen R. Koenig: Well, there’s a range of eating disorders: anorexia, bulimia, and overeating, which is what I treat. So psychotherapy is different for each of them, but because what we do and feel is based on what we think, we talk to clients about, “What are your beliefs about food, eating, and your body?”

Mainly what I find is people have a lot of trauma and family dysfunction and use food as a coping mechanism. Psychotherapy is key to treating eating disorders because very often clients have dysfunctional families or they have trauma, and they use food or a focus on weight as a way of coping. So without psychotherapy, you’re just treating the behavior. You’re not really treating the root cause.

Kevin Pho: So what are some misperceptions about eating disorders that you’ve experienced? You’ve been doing this, I assume, for a long time now. What are some common misperceptions about eating disorders that you would like to help clear up?

Karen R. Koenig: Well, you know, if I had my way, I wouldn’t even call them eating disorders. I certainly wouldn’t. We’d call them problems on the mental health continuum, in how people relate food to their bodies, their life skills, and their intrapsychic problems. So if we’re not treating the mental health issues, we’re just not treating it.

Kevin Pho: All right, so let’s talk about your KevinMD article. It’s titled “5 tips for treating high-weight patients.” Now, for those of you who get a chance to read your article, just walk my audience through it. Share the story, why you decided to write it.

Karen R. Koenig: Yes, and a perfect example is a client of mine who kept having stomach problems. She is higher weight, and she didn’t go to the doctor. She finally did. She called me from the hospital, having hernia surgery. She didn’t want to go, and there are five reasons she didn’t, which you’ll listen to.

She didn’t feel heard. She’d be talking to the doctor, and the doctor would be typing notes, and she understands the pressure. I do too. But especially people of higher weight really need that eye contact.

They want their health concerns addressed. Surprise, they know they’re higher weight. Most of them have dieted, lost a hundred pounds, and gained it back. This is the bane of their existence, their eating and their weight. They’re coming for other problems, which may or may not be weight-related. I weigh about 95, and I have knee problems. Obviously, for some people, weight is a problem for their knees, their back, and other things.

They fear being judged. That’s the biggest issue. And when we look at studies, I wrote a book with an MD, Helping Patients Outsmart Overeating, and the studies that we have in the book show that there’s a tremendous bias in the health care industry against higher-weight people, as if, one, they don’t know they’re high weight, and two, they don’t care.

They don’t want to be told to be put on a diet. It’s been known since the 1980s that 95 percent of people who diet and lose weight regain it, and 90 percent regain even more. They have dieted. They’re not there to talk about their weight for the most part, or their eating.

And last, they want to be seen as a whole person, not just a fat, higher-weight person. They really want what everybody else wants when they go to their doctor.

Kevin Pho: So what are some tips that you give clinicians in the exam room when we deal with higher-weight patients and they come up with some of these fears and concerns? What are some tips that you can share with clinicians?

Karen R. Koenig: I’ll tell you, the biggest one is for every clinician to examine themselves and their beliefs. I have been in this industry for 35 years. I have been high weight, I have been lower weight, and I have my biases, because I grew up in this country. So own them, and then make sure they don’t get projected when you’re with the patient. That is the biggest thing to get through and get past, because, yes, most clinicians do. “You have a bias? Are you prejudiced against Black people?” “Oh, no, I’m not prejudiced.” “Do you have a prejudice against fat people?” “Oh, no.” But most of us do, because we can’t help it. So that would really be key.

And then make a special effort to focus on the problem, not mention weight or eating unless the client, or of course the patient, wants to talk about it, ask how you can be of help, maintain the eye contact, smile, and get to know the person as a whole person. So, you know, I think that really works, because people are training MDs, people in my industry and others, but there are MDs training clinicians to focus differently on higher weight. And, you know, we know you’re there wanting to help, so come to us and ask how we can be different.

Kevin Pho: Let’s talk about that self-examination. I think what you’re referring to is implicit biases. If a clinician wanted to self-examine for potential implicit biases against higher-weight patients, what exactly would that look like? What kind of questions should they ask themselves?

Karen R. Koenig: I would start with the same thing we do as psychotherapists. You know, what are your beliefs? Do you believe that obesity is an illness? Do you know what most people of higher weight want to be called? When you see someone of higher weight, what do you think of them? What do you associate? Do you think that they’re lazy, that they don’t care about themselves? So I would ask a whole range of questions of them, and I’m sure there are questionnaires out there to be asked. Again, referring to my book, we have those kinds of questions, so people who want to can rethink how they think about higher-weight people. And if you notice, though it’s longer, I say higher weight or high weight, low weight, because that’s value-neutral. So those are the questions I would ask.

And then I would ask: Do I have trouble even thinking and talking about this? Does it make me uncomfortable? It depends on the caregiver, the clinician’s weight and eating issues. You know, how does that compound the issue and complicate it? Which it does.

Kevin Pho: We’re talking to Karen Koenig. She’s an eating disorder therapist. Her KevinMD article is titled “5 tips for treating high-weight patients.” Karen, what are some of your take-home messages that you want to leave with the KevinMD audience?

Karen R. Koenig: That you’re not bad because you have biases. That’s entirely what our culture tells us, constantly. So the first thing is to not feel shame about it, to be open to changing, and to look for books and articles that can help you. It will make a huge difference to you and to your patients.

Kevin Pho: Karen, thank you so much for sharing your time and insight. Thanks again for being on the show.

Karen R. Koenig: Thanks for having me. I appreciate it.

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