Unhealthy dietary intake and inadequate physical activity are the foundation of many chronic diseases that plague the human race. These behaviors have their roots firmly planted in a society that has increasingly engineered physical activity out of our lives, and made available food that is high in fat and calories. The combination has turned deadly for our society. Low aerobic fitness, a consequence of sedentary lifestyle, is associated with a 56% increased risk of heart disease¹, and a 35% increased risk of Alzheimer’s dementia², compared to individuals with high cardiorespiratory fitness. It’s estimated that physical inactivity accounts for 1 in 10 deaths worldwide; and if physical inactivity could be reduced by just 25%, 1.3 million deaths could be averted each year.³ Likewise, diets high in saturated fat are associated with higher rates of heart disease.^{4, 5}

With such compelling evidence regarding the risk of unhealthy dietary intake and inadequate physical activity, along with the benefits of meeting recommended guidelines for diet and activity, why does our society still struggle with these behaviors and the subsequent consequences? The answer to this question is long and complicated. In the simplest of terms it can be explained from a socio-ecologic perspective with firm biological underpinnings. Our genetics certainly play a pivotal role in behavior and behavioral consequences. Yet equally important is where we live and with whom we live. The latter concept has become increasingly well-developed in the past decade, where we have come to understand that people who associate with healthy friends (who eat better and move more), are in fact more likely to be healthy themselves.⁶ The converse also holds true, such that people who are obese tend to have obese friends.⁷

These findings suggest that efforts to reverse trends in obesity, and other chronic diseases resulting from diet and inactivity, need to address not only biology, but also environment, social networks, and ultimately behaviors.

Behavior change is one of those 14 letter phrases that is so easy to say, yet so hard to do. Ask anyone who has tried to quit smoking or lose weight, and they will most likely tell you how hard it was. There are many components that play a role in successful behavior change, such as knowledge, attitudes, beliefs, and barriers. What’s important to note here is knowledge alone is not enough! A recent meta-analysis by Rose, et al., entitled, Physician weight loss advice and patient weight loss behavior change,⁸  found that physician counseling regarding weight loss results in clinically significant weight loss. Studies in the meta-analysis generally included and assessed the impact of a behavioral component, such as motivational interviewing, use of the 5As, and communication skills of the physician. It also bears mentioning that the U.S. Preventive Services Task Force (USPSTF) recommends intensive lifestyle intervention for obese individuals seeking weight loss.⁹

In this issue, Dr. Janet Rankin, has nicely summarized the literature on diet and exercise interventions aimed at improving body composition in individuals with obesity. In it, she reports that the optimal diet to achieve a leaner physique is moderate in total calories, low in fat, and higher in lean protein. In addition, she concludes that exercise alone is insufficient to result in significant weight loss, but in combination with the aforementioned dietary changes, 250 minutes/week of moderate intensity aerobic exercise and twice-weekly resistance training can result in clinically significant changes in body composition.¹⁰

Given the overwhelming volume of information on diet, this summary is a valuable source of information for clinicians who, come January 2, will be face to face with patients who seek their counsel on achieving current New Year’s resolutions. For those clinic visits to be meaningful for patients, clinicians will need to: 1) integrate content knowledge imparted by Dr. Rankin’s paper; 2) incorporate behavior change strategies including prioritization and readiness for change; and 3) develop an understanding of the resources and barriers that impact the patients’ ability to change.

The 5As have emerged as an effective strategy for approaching behavior change. This model is endorsed by the Centers for Medicare and Medicaid Services and the USPSTF.⁹ The 5As do not represent rigid linear steps, but rather help shape an ongoing conversation that promotes successful behavior change; Dr. Rankin advocates for this approach as well. Primary care providers should consider this as a structure to guide conversations with patients. Using the structure provided in the article, “Assess” includes assessment of lifestyle and health risks, behaviors and concerns. Next comes “Advise” the patient on personal health risks in addition to evidence-based interventions and behaviors. The third step is “Agree,” which is critical in helping the patient focus on 1 to 3 specific goals based on personal preferences and readiness to change. “Assist” includes supporting the patient by making an action plan promoting accountability and identifying resources. This is the place for SMART goals – Specific, Measurable, Attainable, Realistic, and Time-based. The fifth A is “Arrange.” This may include arranging a referral to a personal trainer or physical therapist, if needed. It may be to arrange follow-up to adjust goals, clarify the treatment plan, and assess progress. Changes in healthcare coverage have made this final A harder to implement. Patients on high deductible health plans may be reluctant to pay out–of-pocket for follow-up visits. However, it’s important to keep in mind that provisions of the Affordable Care Act also provide coverage for Medical Nutrition Therapy (MNT) with a dietitian, and intensive lifestyle counseling for Medicare enrollees with a primary care provider. It’s beyond the scope of this article to delve into the details, but providers should make themselves aware of federal and local coverage for these services.

Finally, it’s worth mentioning that even minimal weight loss can have a profound impact on health outcomes. One does not need to lose 50-100 lbs to realize significant reduction in health risk. For example, the Diabetes Prevention Program found that even a 7% weight loss (17.5 lbs for a 250 lb person) can significantly reduce the likelihood of developing diabetes.¹¹ Obstructive sleep apnea (OSA) is another condition associated with obesity. For every 1% decrease in weight, there is a 3% decline in the risk of OSA.¹² Osteoarthritis is one of the most prevalent chronic medical conditions.  Weight loss of only 15 pounds can cut knee pain in half for overweight individuals with arthritis.¹³

Primary care physicians are a trusted source of information for their patients. It behooves us to understand what constitutes effective prevention and treatment of chronic disease. The foundation for many lies in unhealthy diets and inadequate physical activity. Armed with this knowledge and applying sound behavior change principles, we can help our patients achieve their goals and improve their health.

References:

1. Kodama et al. Cardiorespiratory Fitness as a Quantitative Predictor of All-Cause Mortality and Cardiovascular Events in Healthy Men and Women: A Meta-analysis. JAMA The Journal of the American Medical Association, 2009; 301 (19): 2024.
2. Willis BL, Gao A, Leonard D, DeFina LF, Berry JD. Midlife Fitness and the Development of Chronic Conditions in Later Life. Arch Intern Med. 2012;172(17):1333-1340.
3. Lee IM, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT; Lancet Physical Activity Series Working Group. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet. 2012 Jul 21;380(9838):219-29.
4. Hu FB, Stampfer MJ, Manson JE, et al. Dietary fat intake and the risk of coronary heart disease in women. N Engl J Med 1997;337:1491–9.
5. Jakobsen MU, Overvad K, Dyerberg I, Schroll M, Heitmann BL. Dietary Fat and Risk of Coronary Heart Disease: Possible Effect Modification by Gender and Age. Am. J. Epidemiol. (2004) 160 (2): 141-149.
6. Sawka KJ, McCormack GR, Nettel-Aguirre A, Hawe P, Doyle-Baker PK. Friendship networks and physical activity and sedentary behavior among youth: a systematized review. Int J Behav Nutr Phys Act. 2013 Dec 1;10(1):130.
7. Christakis NA, Fowler JH. The spread of obesity in a large social network over 32 years. N Engl J Med. 2007 Jul 26;357(4):370-9.
8. Rose SA, Poynter PS, Anderson JW, Noar SM, Conigliaro I. Physician weight loss advice and patient weight loss behavior change: a literature review and meta-analysis of survey data. International Journal of Obesity (2013) 37, 118 – 128.
9. U.S. Preventive Services Task Force. Screening for and management of obesity in adults: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2012;157:373-378. http://www.uspreventiveservicestaskforce.org/uspstf/uspsobes.htm. Accessed December 17, 2013
10. Rankin JW. Effective Diet and Exercise Interventions to Improve Body Composition in Obese Individuals. Am J Lifestyle Med
11. Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. The New England journal of medicine. 2002 Feb 7;346(6):393-403.
12. Peppard PE, Young T, Palta M, Dempsey J, Skatrud J. Longitudinal study of moderate weight change and sleep-disordered breathing. JAMA. 2000;284:3015- 21.
13. Bartlett SJ, Haaz S, Wrobleski P et al. Small weight losses can yield significant improvements in knee OA symptoms. Arthritis &. Rheumatism 2004; 50[9 (S)], S658.