By Andrew M. Freeman, MD

Have you ever been with a patient who has a staggering medication list and what appear to be endless complications of a poor lifestyle? How many new patients enter your clinic with obesity, coronary disease, stents, congestive heart failure, sleep apnea, and obesity-hypoventilation syndrome on oxygen? After you take a careful history, it seems to you that all diagnoses point to a poor diet and lack of exercise exacting its toll over many years. You might even wonder if a previous health care provider has ever had a honest discussion about obesity as the central underlying pathology with this patient? Will you be the first to be truthful and honest with your patient? Inpatient docs are likely to include any care plan for obesity for their patients only 7% of the time, according to recent studies.¹ We all know that the truth hurts. Being honest and upfront with our patients is a difficult skill to master. Many of the highest-rated "top doc" physicians never even broach the subject of weight loss, obesity, or marked lifestyle changes with their patients because they know how upset and uncomfortable the topic really is. There is always a concern of a patient being offended and going elsewhere, which isn't good for maintaining a client base and business.

Perhaps it's time all physicians work harder on being more honest with patients about the true underlying causes of their disease. I believe it's possible for physicians to be supportive, empathetic, and providers of solutions to combat patients' illness while being honest with them. We need to tell a patient if he or she is overweight or obese, while providing the tools, support, and encouragement to solve the issue.

In its December 28, 2012, issue, The Week Magazine aptly put the idea this way: "For the first time in human history, overeating is now more of a global health threat than hunger... 3 million deaths in 2010 were attributable to excess body weight—3 times the death toll due to malnutrition." And looking to the future, by 2030, obesity will cost between $48 and $66 billion a year in the United States.² Imagine how quickly we could solve our health care epidemic cost explosions and perhaps even balance our budget if we told our patients the truth.

We all know the data and how we feel when we eat poorly. People who eat the most red meat (~2 servings a day) have a 40% higher risk of dying from myocardial infarction, stroke, or other cardiovascular event.³ Even earlier, say 1999, the Lyon Heart Study showed that simply eating well could markedly reduce cardiovascular events.⁴ Further work by Ornish et al. showed dramatic reversal in coronary disease by angiogram (our gold standard) with diet, exercise, and stress relief.⁵ Hippocrates, the founder of modern medicine, suggested a solution early: "Let food be thy medicine."

Now, taking all of the known research about eating well, living well, diet, and exercise, why are so few health care providers discussing this important topic with their patients? Because it takes time and a solid knowledge base in nutrition, it's not well (if at all) reimbursed, and it's a very uncomfortable topic in a society like ours that relies on pills, stents, and procedures to cure all of our ills. As physicians, many of us have had limited training on how to deliver difficult findings and almost no training on how to treat this epidemic through lifestyle changes.

Isn't an ounce of prevention worth a pound of cure? So how do we do this? How can we get our patients to see the path towards a healthy lifestyle and less need for procedures and medications? A few approaches to consider:

• Practice what we preach: Walk with a Doc is a great program. Started in Ohio as a national program, it is a (now international) program in which patients walk side-by-side with health care providers. No co-pays, no forms—just empowered patients and providers learning from one another and getting healthy together. Find out more at www.walkwithadoc.org. It's amazing what this program does for providers and patients alike.
• Eating better: Believe it or not, eating mostly plants is a great way to lose weight, lower cholesterol and blood pressure, and eliminate a lot of processed foods and chemicals. There is no need to be a strict vegetarian if it's not desired, but the more plant-based, the better. My patients who have "gone vegan" have seen dramatic improvements in blood pressure, cholesterol, weight, and cardiovascular risk—and usually quickly (i.e., 6 months).
• Try new foods: Encourage your patients to try vegetarian/vegan entrées at restaurants. They'll be surprised at how good simple, unprocessed foods can taste and make them feel. Try these foods yourself, then share this info with your patients.
• Offer solutions and learn nutrition: Doctors have little nutrition training (most have had 30 minutes or less). Learn more. Try the Physicians Committee for Responsible Medicine (pcrm.org) and look up their vegetarian starter kit. It's an amazing resource for your patients. The site also boasts loads of information for providers, too. Consider reading Nutrition Action magazine (www.nutritionaction.com), and perhaps visit www.NutritionFacts.org for some interesting views and news.
• Be more patient-centered: Ask if your patient wants to discuss diet (not all do); offer a chance at a lasting "cure" as opposed to control achieved with medicines. Work to incorporate your patients' preferences, ethnicities, and cultures into your diet discussions. Encourage, build up, and inspire your patients to make drastic changes—their lives depend on these changes!
• Embrace the new lifestyle guidelines from the ACC/AHA: Every one of these stresses the importance of lifestyle modification through diet and exercise.
• Be mindful: Learn how stress and mindfulness can actually work to lower cholesterol, blood pressure, and even cardiovascular risk with no medicine at all.

Let's start doing what we want to medical school for: helping patients and preventing disease. Won't you join me?

References

1. Maguire P. Obesity: Avoiding the "Teachable Moment." Today's Hospitalist, July 2012. http://www.todayshospitalist.com/index.php?b=articles_read&cnt=1024
2. Wang YC, McPherson K, Marsh T, et al. Lancet. 2011;378:815–25.
3. Pan A, Sun Q, Bernstein AM, et al. Arch Int Med. 2012;172:555-63.
4. de Lorgeril M, Salen P, Martin JL, et al. Circulation. 1999;99:779-85.
5. Ornish D, Brown SE, Scherwitz LW, et al. Lancet. 1990;336:129-33.

Andrew M. Freeman, MD, is the current chair of the ACC Early Career Section Leadership Council.