Has your doctor ever told you to lose weight and exercise? Did you do it? Obesity is an epidemic in the United States. The chances are 1 in 3 that you've been told that you are medically obese. And chances are you didn't do what the doctor told you to do or, if you did, that you didn't keep it up.
Not a surprise, right? We all know that hardly anyone does what the doctor tells them to do about weight and exercise. Yet a huge part of the effort to improve the health of Americans is getting Americans who eat too much and exercise too little, who love fast food, soda with sugar, watching TV and networking on the computer, to change their eating habits and to exercise so as to reduce obesity and its consequences -- high blood pressure, clogged arteries, diabetes, heart disease, maybe Alzheimer's disease , and protracted periods of chronic illness, disability and premature death.
Let me confess that for years I was one of those Americans who ignored the doctor's orders. At each annual physical, he told me that I had to lose weight. I immediately went out for a bacon cheeseburger with French fries. I figured it would take a minute or so off my life and at the end of it when the quality of wouldn't be so good anyway. I gained 60 pounds, had high triglycerides, high cholesterol, high blood pressure, chronic lung problems (you need more oxygen to carry more weight), and -- well you get the idea.
Just after my 65th birthday, my doctor told me that I have diabetes. I did a quick calculation and figured that I now had ten years less to live and that I would probably be dead within ten years -- which I was absolutely not prepared to be. Over the next four months I took off 40 pounds and began to walk every day. My blood sugar came down, my blood pressure came down, my lipids came down and my lung capacity went up.
What had changed? I had known all along that being fat was not good for me, but I did nothing about it. The likelihood that I would die before my time got me to change the way I eat (hopefully forever). It was the motivation I needed. Earlier warnings had no effect not because I didn't believe them, but because I got more pleasure out of eating than the satisfaction I imagined getting from losing weight. The rational me, who understood the importance of losing weight, was just no competition for the me that loves food.
So here's the critical point. I don't believe that doctors' telling us to change is alone going to bring about the revolution in lifestyle that we need to improve the health of Americans.
Doctors, I believe that you have got to stop behaving as if you believe that telling your patients to lose weight and appealing to their rationality is always going to get them to do it. You have to get real about helping us. (I suspect I'm making the same mistake that you make by appealing to your rationality. There are lots of reasons why you give orders that won't be obeyed, and telling you to cut it out probably isn't going to help very much.)
But just in case you are more open to change than I suspect. Here's one thing you can do. Learn "motivational interviewing"! This is a way of engaging with your patients that will help them draw from whatever motivation they have to change their behavior and lifestyle. It's critical that it is THEIR motivation. What moved me was that I wanted to live past 75. That's not going to motivate everyone. Your job, Doc, is to help your patients understand what they are getting out of being overweight -- such as the pleasure of eating bacon cheeseburgers and French fries -- and to help them to decide to act from other desires. This does take a few minutes, but there is strong evidence that it is effective.
There are other effective preventive interventions as well. You can learn a lot from public health professionals, who got a handle on this during recent anti-smoking and AIDS prevention campaigns.
Patients -- that would be all of us who are overweight (including doctors who could stand to take off a few pounds) -- you need to take responsibility to help your doctors do what they should be doing. When a doctor tells you to lose weight, instead of nodding and smiling, tell them that it's not going to happen (if you believe that it won't), that giving you orders is not going to get you to change. I can't guarantee the impact, but it's clear enough that we need to get beyond the cultural pretense that all patients obey doctors' orders. It's a pretense that is killing us.