An interview with Dr. Bavani Nadeswaran, clinical professor of medicine, certified diplomat of the American Board of Obesity medicine, and a leading expert on obesity management
Ever find yourself staring into the eyes of your patient puzzled by this dichotomy: they take their medications three times a day like clockwork, check their blood sugar four times a day, visit their PCP monthly, cardiologist every three months and endocrinologist every six months, visit the lab to have blood drawn and give a urine specimen every three months, pick up their medications at the pharmacy every month on the 15th. I marvel at the consistency and discipline in their health care regimen, and yet, I am bewildered by the lack of stick-to-it-ive-ness they have shown me with our diet and exercise promise. How could this be?
A patient walking into your exam room is a patient revealing to you that they do, in fact, care about their health and that, to some degree, they trust you with their life. We've all experienced the disappointment of a broken promise that was made during a motivational interview. To find out how to get more out of the doctor-patient lifestyle agreement I spoke with Dr. Bavani Nadeswaran, certified diplomate of the American Board of Obesity medicine and one of southern California's leading experts on obesity management:
Tip #1. Make sure your patient is ready for a lifestyle change
IMTOTL: What are the three most important behaviors a healthcare provider can adopt to help patients stick to their lifestyle goals?
BN: When you're trying to counsel somebody about weight loss, eating healthier, and staying active you first need to see where the patient is in terms of readiness to make changes. You can try saying something like "I am concerned about your weight, do you want to talk about it at today's visit?" and if the patient is ready then it makes sense to make some time to talk that day instead of postponing it. On the other hand, if the patient is in pain, has another concern they want to address that day, or is otherwise not ready at least let the patient know that you are worried about their weight, educate them that it is causing their metabolic and mechanical issues, and let them know that you are there for them when they are ready to talk about it.
Tip #2. Let your patient decide what would be the easiest way for them to restrict calories
IMTOTL: When a patient is overweight or obese they are at risk for metabolic and mechanical issues or may already have them. At this point it becomes critical for them to eat well and a key component of this is restricting calories. If they are ready, how do you get patients to take in fewer calories?
BN: First you have to ask the patient what would be the easiest way for them to restrict calories. Suggest something like a calorie counting app or weighing portions. There are many free apps that make this easy to do on your smartphone. It can be very helpful, especially for patients who eat out. It is surprising to see that a salad might have 1000 calories while a hearty soup is only 300, so it helps you make smarter choices. If this is still too strenuous or time-intensive for the patient suggest a meal replacement like shakes in place of meals or a diet plan like Weight Watchers. Allow them the freedom to change between plans if they become bored with their initial choice.
IMTOTL: What if this is still too complicated for the patient?
A typical low hanging fruit that works for many patients is to eliminate liquid calories. Start by asking "what do you drink throughout the day?" and if it's soda, juice, or sweetened coffee drinks make an agreement to reduce the number of caloric drinks per day. If they are drinking something like sweetened coffee drinks consider replacing that with a meal replacement shake such as Slim Fast or Premier.
IMTOTL: What if the patient asks you about switching from sweetened soda to diet soda?
BN: Diet soda is definitely better than regular soda but anything that has carbonation increases borborygmi (churning of the stomach) so it increases hunger about 2 hours later. I advise patients to drink unsweetened iced tea or use Crystal Light to sweeten drinks.
Tip #3. Let your patient tell you which physical activity they will be able to enjoy and maintain
IMTOTL: I find it very difficult to get my patients to stick to simple exercise such as trying to get 5,000 to 10,000 steps per day. How do you get your patients to achieve exercise goals?
BN: Exercise is not one-size-fits-all. It's important to ask your patient if they have an activity or sport that they enjoy and have them add that to their regimen. As far as step-counting goes, when the patient has a BMI over 35 or 40 new aggressive physical activity such as walking 6 miles per day could cause injuries or worsen existing pain. They key here is just to get them to move more. If they are currently getting 2000 steps a day get them to do 4000 or 5000. If they are able-bodied but not getting enough steps due to a sedentary job ask them to set a goal for 10,000 steps per day and if they don't reach their goals they can make it up on their days off. At work they should park far away, take stairs instead of the elevator, walk over to talk to a colleague instead of texting or calling, stand or pace while on the phone, walk instead of drive to lunch, and do simple exercises like 10 squats every hour if their work area permits. In the end it's all about which physical activity your patient will buy into so that they can stick to it.
IMTOTL: And what is one guideline relevant to your field that an internist cannot live without?
BN: The AHA/ACC/TOS guidelines for obesity management. They are very detailed, they have useful algorithms, and even tools for motivating patients.
Dr. Nadeswaran went on to say that if your patient has faithfully tried all of your recommended interventions and is still not losing weight, in some cases it is reasonable to consider weight loss medications. Some of these require special certification to prescribe and patients may require certain lab monitoring. If you are unable or unwilling to do this consider referring to an obesity management specialist.