Can We Talk?

Properly Framing Conversations About Healthy Patient Lifestyles Is Key to Success

May 17, 2010 08:25 am Hannah DeClerk

As America's collective waistline continues to expand -- and the health of millions of its residents declines as a result -- it becomes ever more essential that primary care health professionals offer guidance on weight-related issues and reinforce the importance of healthy living in their patients. Fortunately, they are in an ideal position to do so.

According to Colleen Fogarty, M.D., an assistant professor of family medicine at the University of Rochester Medical Center in Rochester, N.Y., it's critically important for FPs to discuss weight and healthy lifestyles with their patients, especially those patients with multiple comorbidities.

Fogarty told AAFP News Now, "Having conversations with patients about healthy, calorie-appropriate eating and physical activity is crucial, especially with parents of young children."

According to the Weight-control Information Network( of the NIH's National Institute of Diabetes and Digestive and Kidney Diseases, or NIDDK, primary care health professionals are in an ideal position to offer guidance to patients who are overweight or obese and help them adopt -- and maintain -- healthy lifestyles.

The key to speaking with patients regarding weight issues lies with starting that conversation the right way.

Approaching the Conversation

Many patients are willing to talk about weight issues with health care professionals who offer respect and empathy for their struggles with weight control, according to the NIDDK.

However, before starting the conversation about weight control with their patients, family physicians should take a few minutes to talk about other issues that may be affecting a patient's physical or emotional well-being.

To properly address lifestyle and weight-related issues with an unhealthy patient, it is important to begin with a "healthy living assessment" to determine the impact of the patient's unhealthy lifestyle, according to Fogarty.

"Assessing the patient for his or her goals, willingness to discuss body weight, and his or her interest in addressing it are the next steps," said Fogarty.

She explained that it is best to not begin with a direct diagnosis, but instead to get the patient's permission to speak about his or her weight. "A family physician should first ask the patient, 'Is it OK if I discuss your weight with you today?'" said Fogarty. "Then, if the patient agrees, start by asking the patient how he or she feels about his or her body weight."

Fogarty said that after she receives the patient's perception of his or her health conditions, body image and goals, she then documents the weight and height of her patient to calculate the patient's body mass index, or BMI.

"Giving the patient his or her BMI number and information (about what it means), along with specific advice about an initial weight goal, is important," Fogarty said. "Many patients who are in the overweight category don't recognize that they are overweight."

A BMI of 30 or higher is consistent with a diagnosis of obesity, and a BMI between 25 and 29.9 indicates overweight.

Fogarty said she then discusses her patients' unhealthy lifestyles in relation to their health problems.

"Many of my patients have hypertension or diabetes mellitus or both, and weight loss can benefit these conditions," said Fogarty. "Knee, hip and back pain is often aggravated by the strain of excess body weight. I think connecting the unhealthy lifestyle to a diagnosis can be a big motivator, and gets across the message that the physician is caring for the whole patient."

Next, physicians can help their patients set healthy lifestyle goals. The goals, however, should be realistic, and they can be as simple as eating less, said Fogarty. "Like other behavior changes, we need to find ways to continue engaging our patients in conversation without blaming, and work with patients when they are ready to make a change in the way that makes the most sense for them."

A patient who is not yet ready to attempt weight control still may benefit from a discussion about healthy eating and regular physical activity, according to the NIDDK.

The 5-A Model to Framing the Conversation

According to FP Colleen Fogarty, M.D., assistant professor of family medicine at the University of Rochester Medical Center in Rochester, N.Y., the "5-A Model," which is commonly used for smoking cessation counseling, can be applied equally well with many other types of behavioral modification.

  • Ask: Start with the patient's perceptions of his or her health conditions and body image or goals.
  • Advise: Give the patient his or her body mass index number, explain what it means, and offer specific advice on an initial weight goal.
  • Assess: Assessing the patient for his or her goals, willingness to discuss body weight, and interest in addressing it constitute the next step. Goals should be realistic.
  • Assist: Assistance should be patient-centered and may include a referral to nutrition counseling, physical activity programs, and/or follow-up discussions in the office.
  • Arrange: Arranging a follow-up, even if it is only getting the patient's agreement to discuss the topic, provides the message that you, the FP, think the issue is important and worth discussing.

Keeping the Patient on Track

Arranging for follow-up, even if it is only getting the patient's agreement to discuss the topic at a subsequent visit, provides the message that you, the physician, think this is important and worth discussing, said Fogarty.

AAFP Past President Michael Fleming, M.D., of Shreveport, La., told AAFP News Now that a big part of convincing a patient to continue to live a healthy lifestyle is the family physician's sensitivity toward that patient.

"To me, this is a very sensitive problem, because I am an obese physician," said Fleming. "The experience of struggling with obesity has made me a more aware doctor, and helped me understand patients and their sensitivity."

Fleming said that if a doctor simply demands that a patient lose weight, that patient will put up a natural barrier. Instead, said Fleming, it is all about setting realistic goals and providing positive reinforcement. "It is important to ask the patient what he or she likes to do. I then try to set goals for my patients based on what they want to do."

He explained that it is all about small steps.

"It is as easy as advising a patient to increase their walking and handing them a step counter. Just by going to the mall and parking further out increases these steps. This is achievable, and my patients can get to that goal and feel good about themselves."