In a world where obesity has reached epidemic proportions, medical professionals are faced with increasing pressure to help their patients lose weight and adopt healthy lifestyle habits. This is no easy task for clinicians, who often have little training in nutrition science or counseling patients on healthy lifestyle changes.
“Most clinicians went into the profession with the greatest of intentions, to help and heal others,” said David Eisenberg, MD, associate professor of Nutrition at Harvard T.H. Chan School of Public Health and executive vice president for Health Research and Education at the Samueli Institute. “However, many tell me that they don’t know about what their patients need the most — practical advice on nutrition and weight loss. Patients are stuck and physicians feel unable to do their job.”
Yet, Eisenberg insists, clinicians can play a key role in helping solve their patients’ weight problems in clinical settings by becoming more informed themselves about the details of what constitutes healthy meals, encouraging patients to see a dietitian or enroll in a reputable weight loss program for in-depth nutrition and weight loss counseling, and helping patients find ways by which those programs may be covered by insurance. “Medical professionals are uniquely positioned to help their patients take control of their weight because they are so accessible to patients,” said Eisenberg. “To do this effectively, physicians must adapt. And in doing so, they can improve and save their patients’ lives.” In this article, Dr. Eisenberg shares advice for clinicians who want to take a more active role in their patients’ health and well-being by advising them on the topics of healthy lifestyle changes and nutrition.
Obesity and the Importance of Healthy Lifestyles
Medical professionals know all too well that the prevalence of obesity in America has skyrocketed over the last two decades and that more than two-thirds of the population is overweight. Statistics cited by the Centers for Disease Control and Prevention (CDC) indicate that nearly 35% of Americans are obese. It is well-documented that being overweight or obese increases the risk for a host of medical problems, including heart disease, high blood pressure, diabetes, certain types of cancer, high cholesterol, sleep apnea, and osteoarthritis. Studies show that even moderate weight loss reduces the severity of many of these conditions.
Common knowledge accompanied by a robust body of evidence dictate that healthy lifestyle habits —exercising, eating a balanced diet and reducing stress — promote weight loss, prevent weight gain, and enhance overall health. In fact, in 2011, the Center for Medicare and Medicaid Services (CMS) approved Medicare coverage for intensive behavioral therapy as a treatment option for obese patients. Further, while the weight loss industry earned more than $60 billion in 2014 according to market reports, a survey conducted by Fortune reported that more than three-quarters of Americans are watching what they eat. Despite these efforts, obesity rates continue to grow.
Patients are stuck and physicians feel unable to do their job
For many segments of the population, behavior change and adopting a healthy lifestyle is particularly challenging. Individuals living in low income and food insecure communities are affected by high stress, unsafe neighborhoods, lower education levels, lack of resources, and limited access to healthy foods. Much research shows that adults and children living in these communities are more likely to be overweight or obese. Paradoxically, in this population, a lack of food is associated with weight gain because the quality of food consumed is lower. Further, healthy food is more expensive. A meta-analysis conducted by Harvard researchers — comparing diets high in fruits, vegetables, nuts and fish with diets low in these foods and high in processed foods — showed that it costs approximately $1.50 more per person per day to eat healthier. This amount is no small sum and families often find the cost of eating well to be incredibly prohibitive to a healthy lifestyle.
Despite these challenges, Dr. Eisenberg believes that physicians can help people eat healthier foods and manage their weight. “It is our role as doctors to teach people how to create quick, affordable meals by giving them practical advice.”
With so much evidence pointing to lifestyle and nutrition interventions as a means of helping overweight patients lose weight and improve their health, the question becomes how can clinicians effectively teach healthy lifestyle habits?
Clinicians’ Role in Reducing Obesity
The past several years have marked an increased dialogue about treating overweight patients in the primary care setting. In 2013, the American Medical Association declared obesity a disease, making it an issue that all physicians, working with dietitians and other health care team members, should aim to screen for, diagnose, treat, manage, and prevent exactly as they do other diseases such as diabetes and cancer. This team approach is critical to helping patients lose weight and keep it off.
A new guideline published in 2013 by The Obesity Society, the American College of Cardiology and the American Heart Association encourages physicians to take a more active role in helping their patients lose weight. Some of its recommendations for clinicians are to calculate body mass index (BMI; the most widely used screening tool for obesity), make overweight and obese patients aware of their BMI, and advise them of lifestyle changes to lose weight.
An ever-increasing body of research documents the numerous benefits of physician-patient communication around weight loss and healthy lifestyles. Not only does it improve health outcomes, but it enhances patient satisfaction, the patient-clinician relationship, and treatment adherence. A first step in communicating about weight in the primary care setting is measuring BMI and giving the patient feedback. A 2014 analysis of more than 5,000 participants in the National Health and Nutritional Examination Survey (NHANES) found that patients whose doctor had informed them that they were overweight were significantly more likely to lose weight by engaging in healthy lifestyle changes. Researchers conclude that even when patients know they are overweight, they continue their current behaviors unless physicians mention their weight — thus it is physicians’ responsibility to initiate these conversations.
A 2013 meta-analysis that included more than 205,000 patients showed the positive effects of physicians talking to patients about their weight and healthy lifestyle behaviors. Researchers found that greater physician engagement resulted in greater weight loss for patients — and better health outcomes. In 2012, a report in Patient Education and Counseling reviewed 50 studies on behavioral interventions in the primary care setting. In the studies that were successful, behavioral counseling was the most frequently used method, followed by motivational interviewing, education, and advice. The study showed that physicians and nurses were both equally able to provide behavior change advice in the primary care setting. The problem, then, is not their ability to counsel their patients but the fact that this is not occurring on a large scale.
Even moderate weight loss reduces the severity of many conditions
Much research also points to the idea that patients model their providers’ behavior. “My work has been heavily influenced by research led by Erica Frank from the University of British Columbia in Vancouver,” said Dr. Eisenberg. “She found that patients are more likely to take advice from doctors who lead healthy lifestyles and ‘walk the walk.’” For instance, patients are more likely to listen to a doctor who tells them to wear sunscreen daily if that doctor wears sunscreen daily. Research led by Eisenberg, shows that doctors can be trained to improve their lifestyle behaviors and this training positively impacts their ability to counsel their overweight patients and guide them towards healthy changes.
A Work In Progress
Despite mounting evidence that provider communication and counseling is effective in helping patients change lifestyle behaviors and lose weight, there is more work to be done in this area. In a recent study conducted by the National Heart, Lung, and Blood Institute, researchers set out to identify whether clinical guidelines around identifying and treating obesity in the primary care practice setting were being followed. They recorded more than 500 primary care visits with obese or overweight patients and their found that weight or BMI was discussed in only half of all visits. Further, a mere 35 percent of visits included a discussion about a treatment strategy and weight loss options for the patient. While this study shows that talking to patients about their weight is a powerful first step in treating obesity, it highlights that these discussions are not happening as often as they should.
Unfortunately, communication may be especially absent for the patients who need it the most. A 2014 study of more than 6,500 patients showed that obese patients reported lower levels of patient-provider communication. This was measured by a patient questionnaire asking about providers’ listening ability, show of respect, caring about what they had to say, involving patients in treatment decisions, and overall time spent.
A number of barriers prevent clinicians from engaging with patients about their weight in the primary care setting. Most notably, weight is a sensitive and difficult topic. “The question I get asked most frequently is how to broach the subject and how to talk to patients about their weight without being judgmental,” said Dr. Eisenberg. “It’s a challenging task and many clinicians struggle with it.” According to a 2010 study published in Preventative Cardiology, less than one-fifth of attending physicians surveyed and only 10 percent of medical trainees felt confident engaging their patients in conversations about their weight.
Another notable barrier is that medical education does not prepare doctors with knowledge about nutrition. “To become a doctor, you don’t need to know anything about nutrition science,” said Dr. Eisenberg, citing a study that found only 25 percent of medical schools provide the recommended 27 hours of nutrition education. “And even when they do understand nutrition science, many medical professionals do not know how to translate it into practical advice for patients, such as what foods to avoid and how to cook.”
Talking to patients about their weight is a powerful first step in treating obesity
With these barriers, it’s challenging for physicians to advise their patients about nutrition in the clinical setting. Nevertheless, Dr. Eisenberg insists that it must be done. Here, he offers several tips for clinicians on how to talk to patients about their weight:
- Screen patients. If an initial dialogue about weight isn’t taking place, healthy habits won’t follow. The step to begin talking with patients about their weight is to calculate BMI, communicate it to patients, and talk about what it means.
- Enter the conversation in a non-judgmental way. “Physicians are rarely trained on this in medical school, but it’s so important,” said Dr. Eisenberg. Saying something short and simple that conveys your concern for their weight (or blood sugar or cholesterol) is the best way to broach the subject. Be direct but not judgmental. Be factual but compassionate.
- Try motivational interviewing. “This method has been shown time and time again to help physicians guide their patients through the behavior change process,” said Dr. Eisenberg. The technique engages patients and elicits their desires and goals, helping them to communicate more openly about their behaviors and ultimately to facilitate their personal behavior change process.
- Learn about nutrition science — and how to distill it down. Dr. Eisenberg recommends not only reading the news and becoming educated about nutrition, but thinking about how the science can be conveyed in simple language that patients will understand and be able to apply.
- Build strong relationships with dietitians and refer patients to them for treatment. Have a member of your office staff help your patients determine how those visits can potentially be covered by insurance.
- Be a role model. Research shows that patients take advice from doctors who practice healthy behaviors themselves, so reflect on your own lifestyle habits. In conversations with your patients, draw examples and advice from your personal experiences.
- If you don’t already, start cooking. If you don’t know how, learn. “It’s a myth that healthy and delicious cannot coexist,” he said. “We as physicians can teach our patients how to build meals that are heart-healthy and taste incredible. If we can change people’s notions of how easy it is to cook, it will change their health.”
Dr. David Eisenberg co-directs Healthy Kitchens, Healthy Lives: Caring for Our Patients and Ourselves at Harvard T.H. Chan School of Public Health. To learn more about this opportunity, click here.