Examining clinicians’ approaches to discussing weight during routine diabetes care: an observational study

Weight management is an essential part of diabetes care, but discussing weight and weight loss in the office remains a challenge. To determine how clinicians approach this potentially stigmatizing topic during routine primary care, we analyzed videorecorded clinical encounters from a randomized clinical trial that compared usual care with and without an agenda setting kit intervention (QBSAFE, NCT05553912). Using an ad hoc codebook, two researchers reviewed and independently coded video recordings of primary care visits with eligible patients with type 2 diabetes (HbA1c ≥ 8%, fluency in English or Spanish, and BMI ≥ 25 kg/m 2 ). The codebook noted whether the patient or the clinician initiated weight-related conversation, words used to describe weight, the type of conversation that occurred, and any interventions recommended. Binary and multinomial mixed models assessed the statistical significance of relationships between variables. Investigators coded 123 clinical encounters involving 47 male and 76 female patients with mean age 56, mean BMI 32 kg/m 2 , and mean HbA1c 10%. Weight was discussed in 48 encounters (39%), with clinicians initiating the conversation in 27 of these (56%). Clinicians frequently recommended dietary changes ( n = 21, 44%) and diabetes medications associated with weight loss ( n = 25, 52%). Bariatric surgery was not discussed. Of note, weight was significantly more likely to be discussed with patients on GLP-1 receptor agonists compared to those not on these medications ( p = 0.03). Clinicians did not use the terms “overweight” and “obesity,” favoring a discussion of “weight.” Weight conversations occurred in less than half of routine clinical encounters in our study, which were focused mostly on medication use and lifestyle changes and avoided potentially stigmatizing language. While the use of less stigmatizing language appears to be improving the quality of clinical encounters, additional studies are needed to define interventions that will increase the frequency of weight conversations in diabetes care. This study makes use of data from the QBSAFE trial (NCT05553912), registered on September 26, 2022 with the United States National Library of Medicine’s ClinicalTrials.gov.