Posted By: Angela Golden, DNP, FNP-C, FAANP, FOMA 
Many areas of healthcare are starting to talk about the importance of shared decision-making (SDM), which is when the healthcare professional (HCP) and the patient work together to create a plan of care. In obesity care, I think it is very important because patients have experienced and dealt with a lot of bias and stigma in the healthcare environment. SDM helps patients understand that the HCP is there as a partner in their treatment plan. What most of us have found is that when we start doing SDM in the way it was designed, it actually streamlines creating a plan of care. It allows us, as the HCPs, to give the patient the best evidence that we know of today for treatment and what the options are. SDM gives the patient the time and space to think about it—perhaps to do a bit of investigation—and then to have a discussion about what the plan of care is.
You can have an appointment with the patient where you discuss the options, but I think HCPs should always remember that patients typically remember approximately 10% of what they hear during an appointment. It is important that we have informational documents for patients to take with them or that are available in the patient portal to look at later. Obesity is a chronic disease, and time is on our side. We can allow patients the space and time they need to make an informed decision about their care.
Helping Patients Understand Their Health and Choices and Providing Support Without Judgment
An essential component of SDM is making sure patients understand their health condition. Unfortunately, many HCPs do not understand that obesity is a chronic disease and the multifactorial causes behind it. In comprehensive obesity care, many decisions must be made, including an eating plan that works for the patient, how activity is going to be increased, medication vs surgery, or medication and surgery. I think the HCP is the integral piece, providing expertise on the available options in a way the patient can understand. Patients can then think about which of those options fits best with their lifestyle.
We need to remember that with SDM, it is the HCP’s responsibility to support the person, regardless of whether we agree with them. We all have had patients who have said, “I am not going to do that.” I have a patient with abnormal cholesterol levels who should be taking a statin. We have reviewed the pros and cons, and she has opted to do nothing. It was hard to not tell her that she should not make that choice, but I let her know that I would like to revisit her decision at a later date. We kept the door open for further discussion. You should not make someone feel like you are not willing to continue to care for them because they have made a decision that you do not think is the best one for them. To understand their decision better, you can ask in a nonjudgmental way what led them to make it. From their answer, you may find out that they just need more information, which you can provide them—without judgment—and I think that is critical for SDM. This may change their decision or it may not, but you can be confident that they have the correct information, and you can bring the topic up again in the future if appropriate.
I also think it is important with SDM that HCPs remember to talk to the patient at the level of their education. The discussion will be different depending on whether I am talking to a person who did not get an opportunity to graduate from high school vs a person with a PhD. If the patient does not understand what the HCP is saying, then SDM cannot work.
Furthermore, our presentation to the patient must be neutral so that the patient’s choice is truly a choice. I often have patients tell me that I gave them great information and then ask for my advice. This means they are ready for me to tell them what I think is their best course of action. I respond by saying: “Based on the evidence, based on what we know about your obesity and your obesity-related complications, I think this is the best route for you in treatment. But is that the route that you want to take?” I always come back to their decision.
What Is the Patient’s Single Most Important Outcome?
Tovar and colleagues presented a poster at Obesity Week 2023 titled “Single Most Important Outcome: Prioritizing Non-Weight Treatment Targets in Obesity Care.” Is it being able to play with their grandchildren sitting on the floor? Is it being able to walk far enough to be able to vacation with their family? Is it to reduce their medication burden from other chronic diseases associated with obesity? I think if we know the single most important nonweight target from the patient, then we can understand how to better help them achieve their goals. Tovar and colleagues found that self-esteem was the single most important outcome in 24% of patients. I am not sure HCPs always consider this when speaking with patients. I think we talk a lot about diabetes and hypertension, and I have done that many times, as I look at obesity-related complications as the most important outcomes to me. We need to know the patient’s single most important outcome, as that helps direct our SDM.
When you know what your patient’s single most important outcome is and you are checking in to see where they are on the trajectory toward that outcome, you can use targeted motivational interviewing questions. For example, if a patient’s goal is to be able to walk around Disney World (approximately 21,000 steps in a day), the HCP can ask the patient about their progress in increasing their steps at each visit. If the patient is not progressing the way they hoped, we can use SDM to figure out how to set a goal that moves them toward that outcome.
The Importance of SDM as a Cycle
In obesity management, we have discussions with patients during office visits; we provide patient education with reliable, searchable resources for them; and then we give the patient time to make a decision. In my practice, SDM is not at a single visit, as I am always circling back and asking questions. Are they still happy with the decision they made? Do we need to rethink that decision? Are they meeting the goals they set based on that decision? I think we occasionally get into that one-and-done thought process where the patient made the decision for a medication, and we stay the course and do not follow up to see how the patient is feeling about that decision as time goes on. We should always circle back and assess how patients feel about their care. If they are unhappy or want to make a change, you can return to SDM to review the patient education materials to see if there is another option they would prefer and if their goal or goals have changed. If they have met an outcome, what is their next most important goal? These discussions and reviews drive the cycle of SDM.
Summary
Investigators at the David Geffen School of Medicine at the University of California, Los Angeles compared using SDM with not using SDM for patients with prediabetes who could choose to participate in a diabetes prevention program or start metformin. Regardless of their treatment decision, patients lost more weight when they used SDM to make the decision vs if they were just handed a prescription. This bears out in my practice, as well. In my experience, I have found that SDM makes patients more committed to the plan of care because it is their plan of care, not my plan of care for them. When it is their plan, they are more committed and more willing to tell me if it is not working.
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