Over the past 3 decades, the prevalence of overweight and obesity has increased dramatically in the United States. A study published in 2016 showed the age-adjusted prevalence of obesity in 2013–2014 was 35% among men and 40.4% among women.1 It comes as no surprise that increased reliance on inexpensive fast foods coupled with progressively more sedentary lifestyles have been implicated as causative factors.2
With the rise in obesity also has come an attendant rise in related chronic diseases, such as type 2 diabetes mellitus and cardiovascular disease. Women who are obese are also at risk for certain women’s health conditions, such as polycystic ovary syndrome, breast cancer, and endometrial cancer.
It is clear that curbing this public health crisis will require concerted efforts from individuals, clinicians, and policy makers, as well as changes in societal norms. OBG Management recently caught up with wellness expert Linda D. Bradley, MD, who shared in her latest book, “Us! Our Life. Our Health.” Our Legacy,” some practical strategies clinicians can use to help their patients manage their weight and prevent or reverse chronic diseases.
OBG Management: In your book you describe Jane, a patient who was severely overweight and who had low self-esteem. 3 You took 2 hours to convince Jane to talk about her clinical problems. That was clearly a heroic intervention on your part as the physician. What advice do you have for time-strapped clinicians who have patients who may need to face mental barriers in order to begin to address physical ailments?
Linda D. Bradley, MD: I think it is important for us not to lecture our patients. I could list all of the things that patients should or could do to prevent or even reverse disease states, in terms of eating right and exercising, but I think motivational interviewing is a more productive approach to elicit and evoke change (see “Principles and practice of motivational interviewing”). I used to preach to my patients. I would say, “You know, if you stay at this weight, you’re going to get diabetes, you’re going to increase your breast cancer risk, you’re going to have abnormal bleeding, you’re not going to be able to get pregnant,” and so on. It is easy to slip into that in the 7 minutes that you have with your patient, but to me, that is not the right way.
With motivational interviewing, our interactions with patients are shaped by:
- asking
- advising
- assisting
- arranging.
We begin by asking permission: “Do you mind if we talk about your weight?” or “Can we talk about your level of exercise?” Once the patient has granted permission, we ask open-ended questions and use reflective listening: “What I hear you saying is that you are concerned you will not be able to lose the weight,” or “It sounds like you don’t like to exercise, but you are worried about the health consequences of that.”
Principles and practice of motivational interviewing
Utilizing motivational interviewing to help patients identify thoughts and feelings that contribute to unhealthy behaviors--and replacing those thoughts and feelings with new thought patterns that aid in behavior change--has been shown to be an effective and efficient facilitator for change. By incorporating the following principles of motivational interviewing into practice, clinicians can have an important impact on the prevention or management of serious diseases in women1:
Utilizing motivational interviewing to help patients identify thoughts and feelings that contribute to unhealthy behaviors--and replacing those thoughts and feelings with new thought patterns that aid in behavior change--has been shown to be an effective and efficient facilitator for change. By incorporating the following principles of motivational interviewing into practice, clinicians can have an important impact on the prevention or management of serious diseases in women1:
- Express empathy and avoid arguments. "I know it has been difficult for you to take the first step to losing weight. That is something that is difficult for a lot of my patients. How can I help you take that first step?"
- Develop discrepancies to help the patient understand the difference between her behavior and her goals. "You have said that you would like to lose some weight. I think you know that exercise would help with that. Why do you think it has been hard for you to start exercising more?"
- Roll with resistance and provide personalized feedback to help the patient find ways to succeed. "What I hear you saying is your work schedule does not allow you time to work out at the gym. What about walking during lunch breaks or taking the stairs instead of the elevator--is that something you think you can commit to doing?"
- Support self-efficacy and elicit self-motivation. "What would you like to see differently about your health? What makes you think you need to change? What happens if you don't change?"
- American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 423: Motivational interviewing: a tool for behavioral change. Obstet Gynecol. 2009;113(1):243-246.
I find these skills useful for addressing anything from smoking to drinking to weight management to excessive shopping—any extreme behavior that is affecting a patient negatively. When a patient is not ready to talk about her clinical problems or make changes, I let her know my door is always open to her and that I have many resources available to help her when she is ready (TABLE).4 In those cases, I might say something like, “I have many patients who really don’t want to talk about this when I first ask them, but I just want you to know, Mrs. Jones, that I want you to succeed and I want you to be healthy. We have a team approach to taking care of all of you, and when you are ready, we are here to help.”
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It is important to provide practical advice to patients—including how much to exercise, the importance of keeping a food journal, and determining a goal for slow, safe weight loss—and provide resources as necessary (such as for Weight Watchers, nutrition, and dieticians). Each day we have more than 30 opportunities to select foods to eat, drink, or purchase. Have a plan and advise your patients do the same. Recommend patients cook their own meals. Suggest weight loss apps. Counsel them to celebrate successes, find a buddy (for social support), practice positive self-talk (positive language), and plan for challenges (travel, parties, working late) and setbacks, which do not need to become a fall. Find an activity or exercise that the patient enjoys and tell them to seek professional help if needed.