Personal practice has shown that expecting the best from a patient can generate healthy results

Studies indicate that physicians either don't feel confident in their ability to counsel obese patients or feel their counseling is ineffective. The art of talking to patients has not been lost, but the skill of how a medical provider can guide a patient through lifestyle change is something that just isn't taught in medical schools or residency programs. Our education system has failed to prepare a generation of physicians on how to take care of an overweight patient. Moreover, patients turn to us for guidance. We need to look in the mirror and recognize we cannot ignore our deficiencies in this area anymore.

So what can primary care doctors and specialists do to address this issue? First we have to decide if we even raise the topic with patients. Some of my overweight colleagues have said, "Look at me, I would feel like a hypocrite if I told someone to lose weight." On the contrary, patients like to see our human side, and raising the issue and even confiding that you yourself have struggled with your lifestyle is a way to bond with the patient.

Intending the best, some physicians think their duty is to convince a patient to change habits or to scare some sense into them. This raises two points. First, no one can force someone to change if they are not ready to, but they can plant the seed of change that could blossom when they are ready to face the challenge. Second, intimidation tactics and guilt rarely succeed in persuading a patient to embark on a lifestyle change venture. Lifestyle change requires a positive attitude. How can the patient achieve this if their physician is projecting negativity? Our goal as medical providers should be to educate our patients, to support them and hopefully motivate them by using candor and positive messages.

Motivational interviewing has been proven to be effective in guiding patients toward making positive decisions regarding their lifestyle. Are you familiar with the model? Do you know how to gauge a patient's motivation level? Sending a patient out of the office with goals we choose could be worse than doing nothing since that patient is likely to fail at their attempt at lifestyle change (repeat failures lead to demoralization and decreased likelihood of attempting change in the future). Patients must choose their own realistic goals.

Ask the patient to reflect back what they think are the unhealthy aspects of their lifestyle. We should ask the patient, where do you think that you might be able to make changes? What foods can you absolutely not do without? What is your biggest obstacle to physical activity? If you're not ready to make changes now, think about what changes you could make. If the patient actually picks out their own biggest offenders then they can pick out what to focus on. There are different workshops and seminars that can be taken for continuing medical education credit on motivational interviewing that would be worthwhile for any physician needing to learn this skill set.

At the Pediatric Healthy Lifestyle Center in San Jose where I work, we use motivational interviewing.

It depends on how one defines success. At the PHLC we focus on preventing disease, and not on weight loss. In our system, pediatricians refer obese 6-18 year olds (if motivated to change) and all obese 2-5 years-olds for intensive nutrition counseling, medical assessment and motivation assessment (the younger the patient, the better success rates are).

Among my patients, 40 percent come in with elevated blood sugars and cholesterol, 50 percent with low HDL, 32 percent with elevated LDL, 31 percent with elevated triglycerides, and 34 percent with elevated ALT (likely surrogate marker for nonalcoholic fatty liver disease).

While our lab data has not been crunched for statistical significance, of those kids with elevated blood sugars, 60 percent showed a decrease; 59 percent showed a decrease in ALT; 54 percent had a decrease in cholesterol; and 43 percent showed an increase in HDL.

The majority of our patients don't lose a lot of weight, but their lab numbers do change, and they improve in other subjective measures such as self-reported energy levels, improved self-esteem and increased ability to do physical activity. The key is to get the ball rolling, and motivational interviewing allows us to counsel a patient if they are ready to embark on change or not and to set realistic goals. My old program director told me success in residency was all about expectations. If we can guide our patient's expectations of themselves, we can help them be successful at managing their own health.

—By Daniel Delgado, M.D.

Dan Delgado, M.D., is director of the Santa Clara Valley Health & Hospital System's Pediatric Healthy Lifestyle Center.