Wednesday, November 30, 2011

Has Your Doctor Ever Taken a Lifestyle History?

Whether you're worried about your weight or not, how you live your life - how you eat and how you play - will markedly impact on your health and well being. In fact it'll impact on your health far more than any drug your physician could ever prescribe.

So why is it that most people have never had their physicians discuss healthy living with them?

Sure, a doc may ask you whether or not you exercise, and might even inquire into your sleep, but do they delve further?

My belief, though unproven, isn't that doctors aren't interested, and it's not that they're unaware of the benefits of healthy living, but rather that they're simply not taught to consider lifestyle in their clinical history taking, nor how to champion healthy living effectively.

So what are the top 10 things I would want physicians to explore with you at a bare minimum?

In no particular order:
  1. How many meals do you eat out (including cafeterias), order in or take out (including prepared supermarket counter foods) per week?
  2. Do you feel comfortable cooking?
  3. How many meals a week do you cook yourself by means of the actual transformation of raw ingredients?
  4. How many glasses of milk, juice, sugared soda and/or alcohol do you drink a day?
  5. What do you put in your coffee or tea, and how many do you drink a day?
  6. What's your typical pattern of daily eating (ie do you miss meals or snacks and what do you typically have for breakfast/snacks/etc.?)?
  7. (If married and/or with children) How many meals a week do you eat together as a family?
  8. What was your favourite sport or activity as a kid and why aren't you doing it today?
  9. How many minutes of simple walking might you be able to add to your day without it being a hardship, and when would it be (ensuring goal here is Specific, Measurable, Attainable, Realistic and Timely)?
  10. (If a parent of still at home children) Are you living the life, food, fitness and health wise, that you want your child to be living, and if not, what do you think you might improve?
While I realize this list is by no means exhaustive (for instance it doesn't touch on other hugely important issues like relationships, friendships, sleep, job satisfaction, parental struggles, sandwich generation issues, socio-economic stressors, etc.) and may only scratch the surface of healthy living, it would certainly help a physician to get a sense of how their patients are managing their two most important determinants of health, and provide a myriad of opportunities to try to help collaboratively trouble shoot common barriers to healthy lifestyles.

Unfortunately, while we physicians are all taught to examine the micro level minutia of each and every physical system in our annual review of systems, I strongly and firmly believe that as far as health benefits go, it'd be far more valuable to our patients to review the macro level of how they're are actually living their lives.

Of course asking those questions up above will also necessitate having answers...and sadly, therein lies the problem.

Medical schools and residency programs may do wonderful jobs at preparing us on how to treat illness with pharmacotherapy, but sadly the vast majority do a respectively terrible job at preparing us how to help patients manage, as Yale's David Katz puts it, "medical destiny's master levers" - forks and feet.

Here's hoping that one day, the day will come where forks and feet get the medical respect they so clearly and desperately deserve.

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  1. This is the type of interview Registered Dietitian's do - unfortunately, in the USA, our services are not usually covered (until a disease like diabetes or kidney disease already exists).

  2. This just came across my email: Medicare Will Pay for Obesity Counseling. To qualify under the new benefit, counseling must be consistent with the "five A's" listed in a U.S. Preventive Services Task Force recommendation, according to CMS's decision memo:

    Assess: Ask about/assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods.
    Advise: Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits.
    Agree: Collaboratively select appropriate treatment goals and methods based on the patient's interest in and willingness to change the behavior.
    Assist: Using behavior change techniques (self-help and/or counseling), aid the patient in achieving agreed-upon goals by acquiring the skills, confidence, and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate.
    Arrange: Schedule follow-up contacts (in person or by telephone) to provide ongoing assistance/support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment.

  3. Hilary11:16 am

    Oh, if only...

    It seems to me that many physicians are so focused on treatment, that they side step prevention! Which could just be the key to a healthier country. Smoking, alcohol consumption, diet, and exercise have an undeniable impact on future morbidity! We can only hope that prevention becomes a larger part of the picture very soon!

  4. Naturopathic doctors also address these issues during most visits with patients, and there's a strong emphasis on discussing these topics with patients throughout the 4 years in school.

    Largely, I feel like most family doctors don't have enough time to truly discuss lifestyle factors with patients during a normal visit, and support them throughout their challenges. Doctors surely recognize the need to inquire about these factors, but only some choose to take the time with patients and make it a part of their practice, as Dr. Yoni said. I wouldn't be surprised if more comprehensive lifestyle intakes are encouraged in the medical community as the years go on, as more and more emphasis is placed on preventative medicine.

  5. Anonymous1:41 pm

    I'd say it could be a factor of time and priority, and fear of giving offense.

    I don't know many people who visit the doctor for a pure wellness visit- generally you're going for something specific. A surprising number of people get annoyed when the doctor asks about irrelevant things like their weight or blood pressure, or that 'wart' on their arm which is steadily growing and oozing. You want your main concern addressed, and quickly, not necessarily your concerns addressed in order of medical priority or severity.

    Then of course this is such an emotionally charged issue for many people as well. I could see someone getting into a serious huff at the questions you posted. Heck, I would get offended at being asked those questions.

    I have to say, the doctors I've been to and those I am accquainted with are practically obsessed with preventative medicine but it can be difficult or frustrating because it relies so much on the person's own understanding and motivation. 'Take this inhaler twice a day' is easier to do and to explain than 'do aerobic exercise twice a day' or losing weight.

    I've heard people giving out about their doctor because he insulted them by telling them that they should lose weight because they were at risk of type ii diabetes. It wasn't the tone they were objecting to, they felt it shouldn't have been said in the first place.

    - patient's perspective on all this

  6. Good tip Yoni about basic counseling. Other questions about fast food and junk food could be ask... There are more formal questionnaires patients can fill in advance too. I designed my own one.
    Here is the link about Medical News: Medicare Will Pay for Obesity Counseling in USA

  7. This definitely hasn't come up in med school so far. I'm at the halfway point though, so there is still hope, and it is helpful to read about it here.

  8. Anonymous9:56 pm

    AMEN! AMEN! If more doctors asked these kinds of questions (and maybe stocked a few basic, healthy cookbooks for the young mothers among us who were never given a good example, to give out as "prescriptions"), the world would be a healthier place. We need more honesty from our doctors. Don't wait until the obese woman is completely physically disabled to tell her to lose weight... help her with HOW, when she can still walk. Prevention is the single most neglected aspect of our health care, and it shows.

  9. Actually, I have been asked those types of questions by doctors, and when I've answered honestly they've given me advice that wasn't consistent with what I told them (i.e. telling me to try getting some exercise when I'd just said that I was walking 2 miles a day and going to the gym four times a week) or directly accused me of lying.

    So now I'm one of those people who gets annoyed when doctors bring up the topic of weight.

  10. I have I never been asked those questions by any doctor I have ever been to...and I generally go for digestive complaints. The thing that amazes me is that I have never been asked if I eat a lot of vegetables or am vegetarian (I do and I am), or if I exercise (yup...6 days a week), or if I drink a lot of water (you bet). So what do I end up with? Every doctor telling me to eat lots of veggies and fiber, exercise and drink water! To add insult to injury, it's only been when I have specifically requested to be tested for things like iron, b12, folic acid, etc. that they have done it...but if they had bothered to ask about my lifestyle, they would have probably recommended those things.

    Unfortunately, this has meant that I have gone to see dieticians and naturopaths, even though I think that - particularly the latter - are often trying to sell me on pseudoscience theories. I'd rather listen to that (and take it with a grain of salt if I find no scientific basis for it), but have someone actually ask detailed questions and listen to me, than to go into the doctor and be quickly told the wrong solution because no questions were asked. A bit sad, really.

  11. Anonymous3:28 am

    Doctors can't be responsible for all aspects of a person's health just as teachers can't be responsible for all learning by a student. Neither are miracle workers. Don't you think that most people have a pretty good understanding of what basic steps they need take to get healthier? At some point people have to take responsibility for their own health. A doctor pointing out that they should not be drinking so much alcohol does little to affect real change in a patient's behavior.

  12. I think that questionnaires like these can create a "teachable moment." Many busy people don't realize how often they are eating out, how many sugary beverages, eating together as a family. If a person is asked all of these questions at once, he might realize that his lifestyle is less healthy than he though.

    The next step would be to say "What small changes could you make to improve your eating habits?" The patient might decide to cut back on sodas, or bring leftovers from last night's dinner for lunch instead of eating out.

    This information can be recorded in the chart so that on the next visit the physician can ask how those changes are going. If the patient has improved in those areas, the next question is, what additional small changes could be made?

    I will say that my physician's office has a paper questioninare for me to fill out while waiting for an appointment. It has several questions about diet, exercise, alcohol intake, etc, and give space for me to write my concerns. I have never had a specific conversation with the doctor about diet and exercise, but I'm active and within a healthy weight so maybe that's why.