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Fat chance: How physicians can help patients lighten their load

The directions are clear: Eat your fruits and vegetables. Drink water. Exercise regularly. Still the numbers on the scale go up. How can doctors get patients to comply?

By Stephanie Stapleton, amednews staff. Nov. 18, 2002.

Why is that doctor wearing a pedometer on his belt? It's simple, said Daniel Van Durme, MD, a Tampa family physician. He wears it as a reminder of a surgeon general's recommendation that people should walk 10,000 steps a day.

Even at his busiest, though, when he runs from exam room to exam room, Dr. Van Durme will still end up short and have to finish on the treadmill in the evening. It's a point he often makes to patients.

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Tips on a weighty issue
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In this context, Dr. Van Durme's pedometer takes on an added purpose -- it becomes a visible teaching tool. It helps him emphasize that exercise goals are doable, but only with deliberate and conscious effort.

"Life is complex. No one has a free hour, whether a doctor, a lawyer, a schoolteacher or a janitor," said Dr. Van Durme, associate professor and vice chair of the Dept. of Family Medicine at the University of South Florida College of Medicine, Tampa. But sedentary lifestyles are as much a risk factor as is smoking -- directly related to heart disease, osteoarthritis and a whole range of other illnesses. His message to patients is clear: Failure to get up and move jeopardizes their health.

Dr. Van Durme is not alone in struggling to communicate this point. Doctors overwhelmingly report that counseling patients on issues of nutrition and exercise is a source of frustration -- both in terms of patients' reactions and on an even more personal level. Physicians' own best intentions to keep fit sometimes fall prey to medicine's long hours and hectic schedules.

For these doctors, finding time to practice what they preach may be difficult, but it is also becoming more imperative as they focus on the obesity epidemic.

Nearly a third of U.S. adults are obese.

Nearly one-third of American adults are considered obese, according to data from the 1999-2000 National Health and Nutrition Examination Survey published in the Oct. 9 Journal of the American Medical Association.

An estimated 59 million people -- 31% of adults 20 or older -- have a body mass index of 30 or greater. In 1994, this number was 23%. Meanwhile, among children and teens between 6 and 19, 15%, or 9 million, are overweight -- triple the proportion of the population in 1980. The poor diets and inactivity behind these numbers contribute to the nation's chronic disease burden, which accounts for seven out of every 10 deaths.

"We're realizing how unbelievably frightening this is," said Linda Korman, MD, an Edison, N.J., internist who specializes in weight loss and management. It used to be that smoking was the No. 1 cause of preventable deaths, but now obesity seems to be overtaking it, added Dr. Korman, a clinical assistant professor of medicine at the University of Medicine and Dentistry of New Jersey -- Robert Wood Johnson Medical School, Newark.

In terms of visible statistics, the ratio of one in every three people being obese seems to hold true, whether counting customers at the mall or people in a physician's waiting room. But these patients often appear unwilling or unable to take steps to prevent the serious health consequences.

It's a battle that George Cowan Jr., MD, a professor of surgery at the University of Tennessee in Memphis, has been fighting personally and with patients for many years. "It's tough like cancer. Very frustrating."

And very complex.

Obesity is overtaking smoking as the No. 1 cause of preventable deaths.

"A big challenge is getting people to focus on what they eat," said Christy Kirkendol, MD, an internal medicine resident in Indianapolis. She starts by asking patients to keep a food diary to track their caloric intake. But compliance even with this step is difficult. Few do it, and often patients don't come back for follow-ups.

Another shocking part of the problem is how "incredibly inactive" people have become, said Philip Ades, MD, a cardiologist and a professor medicine at the University of Vermont College of Medicine in Burlington. "When you look at what is going on, it is not surprising that we got here."

It's the age of fast food, computers and remote controls. People eat out more, snacks are practically a sacrament, and the world has become a hostile environment of calories and food intake, said Dr. Cowan, who has performed thousands of obesity procedures and is also the president-elect of the American College of Nutrition. The result is a considerable public health challenge.

"It is like quitting smoking," said Lawrence J. Cheskin, MD, a gastroenterologist and associate professor of medicine and human nutrition at Johns Hopkins University in Baltimore. "Things now parallel the early stages of tobacco cessation efforts." And it took a lot of energy just to make that dent.

But with time and scheduling tight, some doctors shy away from this investment, instead feeling relief when a patient actually doesn't gain weight. Others, however, maintain that there is something to be said for taking on the issue and being a role model.

"Some doctors don't address [weight and exercise] with patients because they don't address it for themselves," said Melina Jampolis, MD, a San Francisco internist who specializes in bariatric medicine. "You can't expect to have a meaningful conversation with a patient when you are winded from walking down the hall and into an exam room."

9 million children and teens are overweight.

When physicians talk about their own diet and exercise behavior, they generally agree that they are not all that different from their patients.

"It is a huge challenge to get out and exercise," said Michael Schneider, MD, an anesthesiologist in Orange County, Calif., mostly because of the hours. But when it is a priority, it happens. A colleague doesn't schedule surgery before 8:30 a.m. so she can go running first.

Some studies, Dr. Cheskin said, show that doctors are somewhat more adherent, but there is a lot of variability.

What Dr. Schneider sees when he looks around a hospital "runs the gamut." There are plenty of physicians who are overweight, and there are anesthesiologists who smoke. It's hard to say whether doctors overall are healthier than the general population. "As a physician, you are exposed [to the message] more frequently. If you don't internalize it, that's a different problem."

The fact that doctors and patients are in this together plays a prominent role in the physician-patient dynamic. And physicians who admit to not always doing the right thing say it makes them more empathetic.

"I'm pretty good at exercise, not so good at diet," said Verlin K. Janzen, MD, a family physician in Hutchinson, Kan. He exercises five times a week, but also enjoys cooking and sometimes eats on the run. He tells patients: "If there was an easy solution, don't you think I'd be skinny?"

Others use their own personal triumphs as motivation.

Dr. Korman, for instance, lost a significant amount of weight nearly 25 years ago. She has kept it off since then and says it is the reason why she focused on weight management when she began practicing medicine. "I still live it everyday."

And some draw on their personal habits to inspire. Dr. Jampolis, a certified personal trainer, sometimes targets patients who are especially reticent about exercising and tells them to meet her in the morning for a "jump start" walking session.

Overall, doctors agree that the most important element to success is patient motivation -- and even when a patient is highly motivated, it is hard to help them maintain and capitalize on the mind-set. It's a long-term proposition constantly challenged by tempting food images and claims about silver-bullet solutions.

"We're bombarded everyday with ads that losing weight should be easy," Dr. Janzen said. "People hear this. People want a magic answer that will make it happen."

No time to talk about it either

For physicians in the trenches, combating these notions is no easy task. First of all, time can be an issue. There isn't a lot of it, acknowledged Dr. Cheskin, who directs Johns Hopkins weight loss center. But even a short discussion with patients has been shown to have impact.

Another battle is to get patients to stop chastising themselves and instead focus on their weight problem as a disease for which diet and exercise are the treatment plan, Dr. Korman said. "If you can get that far, it usually makes a difference."

It is not good enough to simply tell patients they need to shed pounds. Patients need a how-to framework. If a doctor is most comfortable offering a referral, that information has to be handy. And unfortunately, these weight-loss steps are often not covered by insurance -- which means that patients end up paying out of pocket.

These types of access and financial hurdles are one barrier. But many others exist and underscore the need to raise public awareness and "put obesity and inactivity on par with smoking," Dr. Ades said. Being overweight creates a predisposition for so many problems, but losing weight is an incredible intervention.

In terms of exercise, the usual buzz words are 30 minutes, four to five times a week. Some recommendations, however, suggest as much as 60 minutes a day.

Physicians should be careful not to set the bar too high -- especially when patients are just starting out. "It is counterproductive to give people goals they can't reach," Dr. Ades said.

Most doctors agree that the first step in convincing patients to exercise is focusing on establishing the habit. Encourage them to begin by walking five or 10 minutes a day. Once this is regularly accomplished, urge them to add on.

"I think we as physicians have to make it doable -- help our patients find solutions," Dr. Jampolis said.

It is also important to create expectations that enable patients to sustain their commitment.

"Weight gain is a slow process, and so is weight loss," said Heather Holmstrom, MD, a family physician in Westland, Mich. Patients have to understand this. "Unfortunately, if they don't see immediate results, they often lose motivation. That's why I emphasize things like improved mood, more energy, alertness and other things that they might actually notice right away."

And just as patients have to learn that good nutrition and active lifestyles are a long-term change, physicians, too, have to be consistent in bringing it up time and time again, Dr. Van Durme added.

"Maybe the first and fifth times the patient tunes you out. But it might be the 11th time that gets them off their duff and moving."

ADDITIONAL INFORMATION:

Fat facts

Physical inactivity and unhealthy eating contribute to cancer, cardiovascular disease and diabetes, which together are responsible for at least 300,000 deaths each year. Only tobacco use results in more preventable deaths in the United States.
More than 60% of American adults do not get enough physical activity to provide health benefits. More than 25% are not active at all in their leisure time.
More than a third of young people in grades 9-12 do not regularly engage in vigorous physical activity.
Estimates indicate that dietary changes could reduce cancer deaths in the Untied States by as much as 35%.
A large gap persists between recommended dietary patterns and what Americans actually eat. Only 3% of all individuals meet four of the five recommendations for the intake of grains, fruits, vegetables, milk products, and meat and bean food groups.
Only one-fourth of U.S. adults eat the recommended servings of fruits and vegetables each day.

Source: Dept. of Health and Human Services

Tips on a weighty issue

Doctors say these approaches with overweight patients have been successful:

Treat body mass index and waist circumference as vital signs.
Make it a priority to recognize patients who are overweight and convey to them that the condition is a predictor of health problems. Emphasize that poor diets and sedentary lifestyles are risk factors just like smoking.
Approach obesity as any other chronic condition and put together a treatment plan. It can involve specific diet and exercise suggestions or can be a referral to a specialist, a hospital dietician or to a commercial weight-loss program.
Focus patient attention on portion control and replacing dense, fatty foods with lower calorie, fiber- and water-rich foods that allow them to eat enough to feel full.
Encourage patients who are not active to establish the habit of walking five or 10 minutes daily -- and then build on progress.

No time, no energy... They do it; you can too

Excuses be damned! Here are three examples of physicians who have found ways to make physical activity a regular part of their busy schedules:

George Cowan Jr., MD, a general surgeon and professor of surgery at the University of Tennessee, Memphis; also president-elect of the American College of Nutrition:

Dr. Cowen makes a habit of using the stairs instead of elevators throughout the work day -- even when doing daily hospital rounds -- and does sets of sit-ups and push-ups every morning. He credits this regular activity with helping him avoid gaining 10 to 15 pounds over the years.

Similarly, he says, he knows physicians who don't park their cars in reserved doctors' spaces at the hospital or office, opting instead to walk the extra minutes to the building. "But it has to be day in and day out."

Lawrence J. Cheskin, MD, a gastroenterologist, associate professor of medicine and human nutrition at Johns Hopkins University in Baltimore, and director of the institution's weight management center:

Fitting exercise and good nutrition into everyday life "is a struggle," but if you plan for it, it makes it easier, Dr. Cheskin says.

He has a set appointment at the start of each morning with a stationary bike or treadmill. While he exercises, he watches the morning news or reads newspapers or journals. Building it into his day this way makes it automatic -- like brushing his teeth or showering.

He doesn't have a weight problem, but he does have a family history of heart disease. This motivates him to do what he can to minimize his personal risk.

Melina Jampolis, MD, a San Francisco internist who specializes in bariatric medicine:

Dr. Jampolis walks her dogs daily for at least an hour and does 15 minutes of resistance training in the morning on a weight set she keeps in her garage.

She admits that she can't make it to the gym every day. "I wish I could." But she does make what she calls "lifestyle decisions." Her leisure activities are often tennis or biking. And she takes the time to walk a few blocks to the bank rather than getting in a car and driving.

She tells people with busy schedules to take advantage of opportunities like this to move. "It will help, not hurt, your day."

Weblink

Nutrition.gov, a collection of information and resources from various federal agencies regarding nutrition, dietary guidelines and health management (http://www.nutrition.gov/)

HealthierUS.gov, a federal site offering healthy lifestyle information, including physical fitness, preventive health and nutrition resources (http://www.healthierus.gov/)

Abstract, "Prevalence and Trends in Obesity Among U.S. Adults, 1999-2000," Journal of the American Medical Association, Oct. 9. (vol. 288, issue 14) (http://jama.ama-assn.org/issues/v288n14/rfull/joc21463.html)