On the Road to Change

Making even modest changes in health habits is apparently too difficult for many Americans.

We repeatedly hear that more exercise, watching our diets and losing just 10 pounds can lower our cholesterol and dramatically reduce the risk of diabetes.

Still, more than half of us are overweight, and more than one-fifth have high cholesterol. So-called late-onset diabetes is striking at younger and younger ages, and nearly a fifth of all seniors have it. You have to look pretty hard to find Americans who get the recommended half-hour or more of exercise five days a week.

For a long time, people have been blamed for not taking control of their health, accused of being lazy or unmotivated. But increasingly, behavioral experts are realizing that most folks want to change. They just need help.

Attention is now turning to physicians. After all, they’re in the best position to guide patients through long-term changes in their health habits--and to monitor their progress.

Yet behavioral counseling “hasn’t been incorporated into routine medical practice,” said Jessie C. Gruman, executive director of the Center for the Advancement of Health.

Each year, patients visit doctors 829 million times--an average of 3.1 visits for each patient. That represents millions of potential counseling opportunities, Gruman said.

The nonprofit organization recently surveyed doctors, HMOs and public health leaders and found that when health professionals talk briefly with their patients about lowering their health risks, managing chronic illness and pharmacy use, “they are more likely to attempt and succeed at changing poor health habits.”

Patients are much less likely to adhere to mere instructions to “lose 10 pounds,” “cut back on the sugar” or “watch your cholesterol.”

Take Paul H. Scott, 54, an engineering manager from San Jose who was diagnosed with diabetes. His sugar level was high, “but I didn’t know what that meant. It was just a number,” he recalled.

Rather than heeding his doctor’s advice to lose some weight, he ballooned to 350 pounds, continuing “to eat everything in front of me.”

When his doctor suggested he enroll in diabetes education classes, “I said sure, but I never did,” Scott recalled. “I blew him off.”

To be fair, doctors are working against a tide.

Their messages about tobacco’s link to heart disease and cancer are reinforced by public anti-smoking programs. Society, too, has sent a clear message, stamped on every pack of cigarettes, that smoking kills.

But with overeating or inactivity, social forces conspire against doing the right thing. There are seductive invitations to grab a burger, fries and a super-sized soft drink and plop down on the couch with a channel-changer. That leaves a bigger selling job for doctors, who are often ill-prepared for behavioral counseling.

A New and Unsettling Role for Doctors

Few physicians feel comfortable in the counselor’s role. Most complain they don’t have time for detailed discussions. And they’re not reimbursed for time spent talking--a factor that some say needs to change if counseling is to become routine during office visits.

Furthermore, knowledge about how to instill healthful habits “hasn’t been recognized nor organized nor incorporated into medical training nor into continuing medical education,” said Gruman. “It’s not seen as something that’s as scientifically driven as a prescription for medication.”

Dr. Mitchell Feldman, an internist who trains primary care residents at UC San Francisco, says counseling “is what most clinicians don’t do. They like to treat things with five days of antibiotics and the problem goes away.”

Changing health habits takes time and patience. Doctors may not feel that they’re making a difference. The gratification is often delayed. They may not hear until the next annual visit that a patient has lost the weight, begun to exercise or given up smoking.

Like kids who need to fall off a bicycle several times before learning to ride, most people fail repeatedly before reaching their goal. Doctors often give up on patients after initial failure, even though they frequently have the same difficulties changing their ways. When Feldman asks groups of doctors about their own attempts to stick to some new regimen, they’ll acknowledge it’s tough.

Feldman says primary care doctors often “forget to try to sit back a little bit more and assess where the patient is at. The mistake I see over and over in residents and . . . with many primary care physicians is they don’t really try to assess the person’s readiness for change.”

Some patients are only thinking about change; others are prepared to acknowledge their behavior’s impact but aren’t ready to make the commitment. Still others are making changes and need help with maintenance.

Often, patients don’t get the empathy they need to adopt and sustain new habits that may entail some sacrifice.

“It’s not necessarily what you say, but how you say it: acknowledging that they’re giving up something, maybe something they find very pleasurable,” said Dr. Michael Goldstein, who helps primary doctors promote behavioral changes.

“It’s a matter of helping the person to see the benefits and overcome the barriers, because people are ambivalent about change. It’s not all or nothing,” says Goldstein, an internist and psychiatrist with the Bayer Institute for Healthcare Communication in Milford, Conn.

Shelley Lavender, a Los Angeles arts coordinator, felt overwhelmed by all the changes doctors advised. Two years ago, at age 48, a heart attack and bypass surgery provided the impetus to quit her two-pack-a-day smoking habit. She stopped drinking coffee because it triggered the desire for cigarettes. She gave up most red meat and sugar.

But she still hasn’t taken her cardiologist’s advice about exercise.

“Every time I go in to see her, she says, ‘You should walk 10 minutes a day, 20 minutes every other day,’ but I just don’t have the willingness to do it,” Lavender said.

Behavioral experts say there are ways to get patients such as Lavender to gradually alter their outlook; pushing too hard only will alienate them.

There are many obstacles to regular exercise. For some people, it’s embarrassment; for others, a lack of enjoyment; for many, chronic conditions like arthritis, says David Buchner, chief of the physical activity and health branch of the Centers for Disease Control and Prevention in Atlanta. People with chronic conditions such as heart disease, osteoporosis, diabetes and depression should be counseled about exercise as both a preventive and therapeutic measure because they can benefit greatly, he said.

Exploiting an Opportune Moment

“One thing doctors can do is look for teachable moments,” said Dr. Kurt Stange, a professor of family medicine at Case Western Reserve University in Cleveland. For example, Stange said, “when a smoker comes in with sinusitis or bronchitis and they’re feeling bad, you have more effect.”

Big changes often are precipitated by traumatic events. At those times, doctors can provide reinforcement.

Leonard Balbus of San Francisco, a yoga enthusiast, was 20 to 30 pounds overweight and his sugar and cholesterol levels were excessive, yet diets weren’t working. Finally, he began to think about how many of his relatives were diabetic, including his father, who had died three years earlier, and said to himself, “If I have any choice in the matter, I’m not going to be a diabetic.” He began a low-carbohydrate, high-protein regimen. It worked.

“Last time I checked, he had cured his diabetes,” said Feldman, who encouraged Balbus’ weight loss. “It’s remarkable and very gratifying to see him . . . finally find a diet he could stick with.”

Some health plans, such as Kaiser Permanente, rely on nurse practitioners, pharmacists and health educators to help patients manage their chronic diseases, such as diabetes and congestive heart failure. Sometimes these professionals can offer the additional attention the doctor can’t provide.

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That’s what worked for Scott. His Kaiser Permanente internist, David Sobel, who had become increasingly frustrated as Scott’s diabetes worsened, put him in touch with a health educator who enrolled him in the HMO’s diabetes education classes. After that, everything changed.

Pharmacists taught Scott to test his blood and he saw for himself “how the blood sugar readings correlated to exercise and to diet and also kind of acted as a kind of a nag system.” The numbers suddenly had meaning for him.

After incorporating walks into his lunch breaks, controlling his carbohydrates and monitoring his own blood sugar, Scott is off all medications and 50 pounds thinner.

“I don’t consider myself a success story yet,” Scott says. “It’s the middle of the story and I’m doing pretty good.”

With training, doctors and other medical professionals can successfully steer patients toward long-term changes like Scott’s, according to several studies. In a 1996 study, Jim Sallis, a psychology professor at San Diego State, found that just “two to three minutes of counseling sedentary people made a very substantial impact on their physical activity.”

Sallis has spent a decade working with the CDC to help put more information about patients’ health habits into the hands of primary care doctors, nurses, dietitians and health educators.

He has developed two versions--one on paper and another filled out on a computer--of a program that matches patients’ diet and exercise habits and goals with appropriate suggestions tailored to their readiness to make changes. During the visit, the doctor can then provide personalized advice about beginning or sustaining an exercise program.

Whether it’s working with overweight adolescents or sedentary seniors trying to reduce their reliance on medications, doctors need to realize they can help patients map a route to success, Goldstein said.

“It’s never too late for a clinician to encourage a patient to change.”

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For Success, It Takes Two

Achieving long-term changes in health habits requires effort by both doctor and patient, experts agree.

1. The doctor and patient should agree on what the health problem is.

2. They should set goals and priorities together. Patients must also understand how changing their behavior can help them reach their goals.

3. The doctor and patient should create a plan tailored to the patient’s needs and abilities. The patient should also be informed about sources of support and ways to overcome barriers.

4. The patient’s progress should be monitored by the doctor or his/her staff through return visits or by calls from a nurse practitioner.