How Change Happens

This week, I learned that one of the most frustrating aspects of medical practice that I addressed in print as well as in the clinic, has finally changed. I listened to a lecture online about the current treatment of obesity. The physician advocated “empathy and support”, asking patients about their “weight loss journey”, shared decision making and motivational interviewing. I cackled with delight.

When I was a young doctor, the “shame and blame” treatment of obesity was popular. We were instructed to weigh the patient at each visit, measure their waist circumference and then basically berate them for not losing weight. Surveys showed that doctors, just like the general public, thought that fat patients were lazy and unmotivated. Luckily, at Kaiser Oakland, I met a health educator, Pat Lyons, who called herself a “fat activist” and spearheaded a movement for “health at any size”. She pointed out that the evidence showed that physical activity helped fat people (she never shied away from the f word) decrease blood pressure, decrease risk for diabetes, decrease depression, improve self-esteem—-even if they didn’t lose a pound. And most people who dieted gained back the weight within a year. Those who did manage to keep the weight off were the people who exercised. So why not focus initially on physical activity ? She advocated treating patients with respect, taking a history and developing a program of lifestyle change with them rather than dismissing them with a one-size-fits-no one low calorie diet.

Following Pat’s advice saved my sanity as a primary care doctor, since about a half of my patients were obese. Rather than making them feel bad each visit by pointing out that the number on the scale hadn’t changed, I could be an activity coach, coaxing them off the couch, setting walking goals. And guess what? Exercise, unlike dieting, is self-reinforcing. When you feel better, you are motivated to eat healthier food, too. Blood pressure and blood glucose were easier to control and some people even lost weight. Pat and I used to do trainings together, advocating this approach to obesity. Doctors and dietitians were outraged. We were “coddling fat people”, “condoning obesity”. We doctors should “make” the patient lose weight, not ask them if they wanted to talk about their weight. When my colleagues sputtered indignantly, I asked them Dr. Phil’s question, “How’s that going for you?” Actually, these doctors often achieved what they really wanted —the patients never came back. Whereas my patients were anxious to come brag about how much they were walking. Everyone appreciates respect.

What’s fascinating is that mainstream medicine has now adopted the behavioral techniques that Pat taught me 25 years ago. No one ever admits they were wrong. But change happens anyway.