James A Vohs Award:
A Focus on Obesity, Part 1:
••Spring 2003/Vol. 7, No. 2

Clinical Contributions

Corridor Consult
How Can I Counsel Adults and Children About Weight Management and Physical Activity? | pdf >>

By Margaret McDonough Becker, MPH; Veenu Aulakh, MPH; Sandra Roberts, RN

Introduction

Among Kaiser Permanente (KP) members in Northern California, only about 24.5% of adult patients who are obese or who are overweight with health complications report that they receive advice from their physician about better managing their weight, and only about 18% of sedentary patients report getting advice about increasing their physical activity.¹ These numbers seem low, given the epidemic proportions of obesity, increased media attention, and public pronouncements from national leaders on the ill effects of obesity and inactivity. Fully 64.5% of the US population are overweight, and nearly a third are obese (body mass index (BMI) > 30).²

The Physician's Role in Counseling Patients about Weight and Physical Activity

By advising and counseling patients on weight management and related lifestyle factors, physicians can play an important role in addressing this burgeoning epidemic. Although many physicians cite lack of ability to change their patients' behavior as a primary reason for avoiding discussion of weight control,³ studies have shown that physician counseling can be effective for changing patients' physical activity and eating behavior and can produce weight loss.^4-7

One possible framework for advising patients is described by the acronym AIM, which stands for three aspects of weight management counseling:

• Advise all patients to be physically active;
• Identify at-risk, overweight, or obese patients by calculating BMI;
• Motivate high-risk patients to take steps toward adopting healthy types of lifestyle behavior.

For children, the same (ie, AIM) strategy applies. However, instead of generally advising increased physical activity, physicians should advise all children--regardless of shape and size--to do four things:

• Get up and play hard;
• Cut back on TV and video games;
• Eat at least five helpings of fruits and vegetables every day; and
• Drink less soda and juice drinks (drink water when thirsty).

How, exactly, can a physician counsel a patient about weight control and physical activity when the physician's only opportunity to interact with the patient is a brief office visit? A number of useful strategies are available for effectively counseling patients, even when time is limited. The following is a five-step protocol for using joint decision-making techniques to counsel patients--children as well as adults--about weight management and exercise.

Step 1: Open the Conversation

The physician should open the conversation by asking permission from the patient to discuss the topic. For example, the physician might say, "Can we take a few minutes to discuss your weight and physical activity level?" or "Would you be willing to discuss ways to stay healthy and energized?" If the patient consents to the conversation, the physician should engage the patient by using open-ended questions, such as "How do you feel about your current weight?" or "Tell me about your usual exercise and eating habits."

Step 2 (optional): Discuss Patient's Weight, BMI, or Both

The physician may wish to verbally compare the patient's weight or body mass index (BMI) against healthy standards by saying,

"Your weight (or BMI) is ___; this is above what is considered a healthy weight (or BMI) for your height." Physicians who choose to share this information with their patients should then ask for the patient's interpretation of the information, eg, by asking the patient, "What do you think of this?"

Step 3: Present Options and Resources

An important way to motivate patients is to offer them the options and resources they need to take the first step in managing their weight. These may be introduced by saying, "There are a number of ways to work toward a healthier weight or prevent further weight gain. You might consider these:

• Eat a healthier diet, starting by eating at least five servings of fruit and vegetables each day;
• Increase your daily physical activity; and perhaps
• Enroll in a weight management class given by the KP Health Education Department."

Physicians may choose to have a list of these resources ready to give the patient along with the comment, "Here is a list of classes and resources that might help you work toward making healthy changes."

For children who are inactive or overweight, physicians might also consider suggesting that they reduce their consumption of soda as well as their viewing of TV and video games.

Step 4: Elicit an Area of Focus to Encourage Discussion

A short discussion with the patient can really help to prepare him or her to focus on an area for immediate change. This discussion can be initiated by a simple question, such as the following:

• "What do you think would most improve your weight and health?"
• "What do you see as your next steps?"
• "Can you think of a physical activity you could try tomorrow?"
• "What is one realistic step you think you can take to start eating healthier foods?"

Step 5: Close the Discussion

To close the discussion about weight management and exercise, a physician should summarize the next steps to be taken by the patient. This summary may take the form of a comment ("You've said you think you could try ...") or a question ("Where does this leave you now?").

A physician may also give key advice in the form of a statement, such as

• "Getting regular physical activity is one of the best steps you can take to manage your weight and stay healthy" or
• "A small weight loss (even just ten pounds) can have a positive impact on your health."

For children, this statement may be expressed as "Thirty to 60 minutes of play instead of watching TV can prevent some weight gain."

Finally, a physician should express confidence in the patient, eg, by saying, "I am confident that if you make a commitment to yourself to work toward a healthier weight, you'll find a way to do it. Remember, we have a number of resources at KP to help."

Sensitivity is Important

Because the need to manage their weight is an emotionally difficult topic for many patients, any advice or counseling given to the patient is more effective when the terms used in the discussion are chosen carefully. Table 1 presents some examples of how to discuss the topic with tact and sensitivity.

Acknowledgement

Arne Bondewyn, PhD, reviewed the manuscript.

References

1. Gordon, NP. Characteristics of adult Health Plan members of the Northern California Region membership, as estimated from the 1999 Member Health Survey: Regional and Richmond Medical Center service populations. Oakland (CA): Division of Research, Kaiser Permanente Medical Care Program; 2000.
2. Flegal KM, Carroll, MD, Ogden CL, Johnson, CL. Prevalence and trends in obesity among US adults, 1999-2000. JAMA 2002 Oct 9;288(14):1723-7.
3. Kushner RF. Barriers to providing nutrition counseling by physicians: a survey of primary care practitioners. Prev Med 1995 Nov;24(6):546-52.
4. Logsdon DN, Lazaro CM, Meier RV. The feasibility of behavioral risk reduction in primary medical care. Am J Prev Med 1989 Sep-Oct;5(5):249-56.
5. Lewis BS, Lynch WD. The effect of physician advice on exercise behavior. Prev Med 1993 Jan;22(1):110-21.
6. Swinburn BA, Walter LG, Arroll B, Tilyard MW, Russell DG. The green prescription study: a randomized controlled trial of written exercise advice provided by general practitioners. Am J Public Health 1998 Feb;88(2):288-91.
7. Galuska DA, Will JC, Serdula MK, Ford ES. Are health care professionals advising obese patients to lose weight? JAMA 1999 Oct 27;282(16):1576-8.
   

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