AMA Journal of Ethics®

Illuminating the art of medicine

Journal of Ethics Header

AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. April 2010, Volume 12, Number 4: 331-334.

Op-Ed

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Physician BMI and Weight Counseling

A BMI requirement for physicians would not necessarily increase primary care doctorsí effectiveness in providing weight counseling.

Pamela M. Peeke, MD, MPH

Many people who want to lose weight seek help from their doctors. How much does the physician’s own weight affect the outcome of this interaction? If it appears that the doctor lives a healthy lifestyle, will the patient be more likely to heed his or her advice? The answer is “yes”—with a twist.

Learning Objective Understand why a BMI requirement for physicians would not necessarily increase primary care doctorsí effectiveness in providing weight counseling.

Are doctors hypocrites if they do not practice what they preach? Is it ethical to say one thing and do another? The modern version of the Hippocratic Oath states “I will prevent disease whenever I can, for prevention is preferable to cure” [1]. One would think that to promote prevention by teaching it demands practicing it, too. Furthermore, the American Medical Association’s Code of Ethics asserts that

to preserve the quality of their performance, physicians have a responsibility to maintain their health and wellness.... When health or wellness is compromised, so may the safety and effectiveness of the medical care provided.... Physicians whose health or wellness is compromised should take measures to mitigate the problem [2]

and that there is an obligation on the part of the medical profession to establish “physician health programs that provide a supportive environment to maintain and restore health and wellness” [2]. This sounds like an ethical call to arms (and legs) for physicians to be healthy and effective role models.

Physicians, like much of the American population, are not immune to the challenges of girth control [3]. A recent study of male physicians revealed that 44 percent of them were overweight and 6 percent were obese [4]. Less is known about female physicians. The Nurses’ Health Study noted that 28 percent of nurses are overweight and 11 percent are obese [5]. As in the population at large, some overweight doctors are in denial about their weight [6]. Research has also demonstrated that doctors are susceptible to the same kinds of triggers (e.g. stress at home, skipping meals, grabbing junk food at the office) for overeating and sedentary behavior as the rest of the population [7].

Patient confidence in the advice of physicians who are obese is significantly lower than in the advice of physicians who are not obese [8]. Not surprisingly, physicians with poor personal habits are less likely to counsel patients about a healthy lifestyle [9]. It is more difficult for physicians who are not practicing health-promoting behaviors to be perceived as sufficiently credible teachers [10]. Physicians who are walking the walk appear to be the most effective messengers to communicate behavior change because they are more likely to assertively address the topic and provide realistic guidance to their patients [11].

Primary care physicians, in particular, are held to a high standard of personal behavior. When seeking a surgery intervention, the patient is chiefly interested not in what the doctor looks like, but in his or her technical prowess. Family physicians, on the other hand, provide preventive services and counseling about lifestyle matters, and patients have a higher level of expectation about the doctor’s appearance and behavior. Findings from the Women Physicians’ Health Study noted that being a primary care physician and also practicing healthy habits were the most significant predictors for optimal prevention-related counseling and screening behaviors in clinical practice [12].

The twist is that appearances don’t tell the whole story. Having a healthy BMI (under 25) is no guarantee that the physician is fit, practicing healthy living behaviors, or effectively teaching patients about healthy lifestyle practices. There are many physicians of normal weight whose habits leave much to be desired and who are not physically fit; some physicians who are overweight or obese may make healthy lifestyle choices, including efforts to reduce their own weight. Thinking the heavier physician is less credible, patients may dismiss his or her advice. If, however, that physician initiates an open and authentic dialogue about his or her experience and the realities and challenges of long-term weight management, the patient may recognize the physician as an especially credible guide.

On January 28, 2010, Surgeon General Dr. Regina Benjamin unveiled “The Surgeon General’s Vision for a Healthy and Fit Nation.” In her address, she singled out physicians as “powerful role models for healthy lifestyle habits” and then challenged the health care system to:

  1. Encourage clinicians and their staffs to practice healthy lifestyle behaviors and be role models for their patients.
  2. Use best practice guidelines to teach health professional students and clinicians how to counsel patients on effective ways to achieve and maintain healthy habits [13].

During her first interview, Dr. Benjamin noted that she, too, struggles with her weight and personally identifies with the frustrations experienced by overweight and obese adults who are striving to improve their eating and activity habits. New York Times medical writer and physician Perri Klass also noted that she, like her patients, continues to have difficulty managing her weight. She states that she relates more deeply with her overweight and obese patients because she understands only too well their frustration [14]. Genuine empathy for the obese patient’s plight is often born of the physician’s own weight management challenges. Does sharing one’s humanity and fallibility resonate well with patients? There is a paucity of literature on this subject, but we do know that effective communication about healthy lifestyle is enhanced when the physician can draw from direct experience [15].

The achievement of a mythical “right” BMI is not the goal for physicians. Instead, like all aspects of the art of medicine, the ability to reach an obese patient most effectively is more complex. There are three matters to consider in effectively counseling patients about weight: the physician’s body composition, his or her practice of health-promoting behaviors, and his or her ability to effectively convey the healthy-living message to each patient. First, the physician must aim to achieve and sustain a healthy body composition. This is a dynamic, lifelong process often fraught with weight gains and reductions over time. Second, to achieve their most fit body, the physician must practice healthy lifestyle behaviors. The doctor must walk the walk. Third, the physician must effectively and authentically preach these tenets to each patient. The ultimate reward of health and wellness is thus shared by teacher and student, physician and patient.



References

  1. Lasagna L. The Hippocratic Oath: modern version. PBS: Doctors’ Diaries. http://www.pbs.org/wgbh/nova/doctors/oath_modern.html. Accessed March 10, 2010.
  2. American Medical Association. Opinion 9.0305 Physician Health and Wellness. Code of Medical Ethics. Chicago, IL: American Medical Association; 2008-2009. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion90305.shtml. Accessed March 10, 2010.
  3. Cosgrove-Mather B. Obese doctors take own advice. CBSNEWS Web site. March 13, 2004. http://www.cbsnews.com/stories/2004/03/15/health/main606395.shtml. Accessed March 10, 2010.
  4. Ajani UA, Lotufo PA, Gaziano JM, et al. Body mass index and mortality among US male physicians. Ann Epidemiol. 2004;14(10):731-739.
  5. Manson JE, Willett WC, Stampfer MJ, et al. Body weight and mortality among women. N Engl J Med. 1995;333(11):677-685.
  6. Perrin EM, Flower KB, Ammerman AS. Pediatricians’ own weight: self-perception, misclassification, and ease of counseling. Obes Res. 2005;13(2):326-332.
  7. LaPuma J, Szapary P, Maki K. Predictors of physician overweight and obesity in the USA: an empiric analysis. Nutr Food Sci. 2005;35(5):315-319.
  8. Abramson S, Stein J, Schaufele M, et al. Personal exercise habits and counseling practices of physicians: a national survey. Clin J Sport Med. 2000;10(1):40-48.
  9. Reilly JM. Are obese physicians effective at providing healthy lifestyle counseling? Am Fam Physician. 2007;75(5):738, 741.
  10. Hash RB, Munna RK, Vogel RL, Bason JJ. Does physician weight affect perception of health advice? Prev Med. 2003;36(1):41-44.
  11. Wells KB, Lewis CE, Leake B, Ware JE Jr. Do physicians preach what they practice? A study of physicians’ health habits and counseling practices. JAMA. 1984;252(20):2846-2848.
  12. Frank E, Rothenberg R, Lewis C, Belodoff BF. Correlates of physicians’ prevention-related practices. Findings from the Women Physician’s Health Study. Arch Fam Med. 2000;9(4):359-367.
  13. US Department of Health and Human Services. The surgeon general’s vision for a healthy and fit nation 2010. http://www.surgeongeneral.gov/library/obesityvision/obesityvision2010.pdf. Accessed March 10, 2010.
  14. Klass P. When weight is the issue, doctors struggle too. New York Times. July 20, 2009. http://www.nytimes.com/2009/07/21/health/21klas.html?_r=1&ref=health. Accessed March 10, 2010.
  15. McCrindle BW. Do as I say, not as I do. The new epidemic of childhood obesity. Can Fam Physician. 2006;52:284-285.

Pamela M. Peeke, MD, MPH, is assistant professor of medicine and Pew Foundation scholar in nutrition and metabolism at the University of Maryland School of Medicine. She is global spokesperson for the American College of Sports Medicine’s Exercise is Medicine campaign, chief medical correspondent for Discovery Health TV, and WebMD’s lifestyle and fitness expert.

Diagnosing Obesity: Beyond BMI, April 2010

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