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Why your doctor’s famous last words, “lose weight” are changing.

 

Kaila HoltzOriginally posted on www.whywithkai.com on August 7, 2013. Kaila Holtz is our newest blogger.

Kaila is a resident in Physical Medicine and Rehabilitation. Prior to medical school she completed a Master’s degree in Kinesiology and represented Canada in softball at the 2004 Summer Olympics. She is passionate about helping others optimize their lifestyle through goal setting, making informed choices and tracking meaningful progress in new and innovative ways.

 

In medicine there is a widespread acknowledgement that generalized lifestyle modification prescriptions like “eat less and exercise more” don’t work. Those that favour victim-blaming say efforts are futile and preventive measures may only impact in the highly motivated few. Shifting blame from patient to physician or health care system, there is a growing body of literature suggesting efforts in lifestyle modification are suboptimal because doctors lack the training and skills (and time!) to properly address nutrition, exercise and sleep habits with their patients (1-3). Regardless of the root-cause a large majority of health care practitioners recognize the final outcome of this powerfully dysfunctional trifecta: an increased risk of obesity, cardiac disease and type 2 diabetes. Many if not all chronic diseases plaguing our health care system are associated with sedentary behaviour, and in this post I discuss why lifestyle medicine is an emerging specialty you need to know about.

Personalized lifestyle medicine is a term so new that I’ve never even heard of it. My ignorance is due to many reasons, the most probable being that I have spent the last few years learning how to diagnose and treat disease as a medical student rather than seeking to prevent it in clinical practice. In the first few weeks of my residency people have asked me often what type of medicine I hope to practice. “Bariatric Rehab” I usually say, trying to medicalize my interest in treating and preventing the complications of obesity. “I want to be an expert in exercise prescription” I say to others hoping they will see how having someone trained in complex musculoskeletal disorders would be a wise addition to a multi-disciplinary team given the increased incidence of osteoarthritis and back pain in people that are overweight. Finally and maybe most importantly I hope my specialty expands on my Master’s degree in Exercise Physiology and I will be able translate research in energy metabolism to practical patient interventions and measure success. But until recently, I have been at a loss what that practice could one day be called and how I could explain it to my colleagues.

The area of medicine that looks at the lifestyle people currently live and seeks to optimize it has many names; the three I most commonly see are: functional medicine, evolutionary medicine, and obesity medicine. All are synonymous with lifestyle modifications that try to address how end-stage cardiometabolic complications of a stressful, sedentary life of caloric excess can be prevented. Is “lifestyle medicine” any different of a term? No – but the type of physician that practices lifestyle medicine may be. After a bit of web surfing in the area of Physical Medicine and Rehabilitation (PM&R) I came across The Lifestyle Medicine Institute at Harvard Medical School that offers continuing medical education courses in the area of promoting healthy lifestyles amongst both physicians and patients.

PM&R is a little known specialty that has been classically reserved for spinal cord, brain injury, stroke and neuromuscular disorders in stand-alone rehab hospitals. It was started after WWII when injured soldiers returned from war but couldn’t go home. Rehabilitation hospitals were created to assist individuals with disabilities integrate themselves back into their communities given their impaired function. Physiatrists are medical doctors with five years of specialty training (4 years in the United States) and rotate through disciplines in both medicine and surgery as part of their residency before completing core competencies in classic rehab disciplines. In Canada, PM&R residents also have formal teaching sessions in exercise prescription and a mandatory rotation in cardiac rehabilitation. Physiatry has expanded in recent years to larger community practice in pain and sports medicine as well as other areas outside of neuroscience including burn, cancer and bariatric rehabilitation (in the United States).

Proposed benefits of having a Physiatrist involved in exercise prescription (4):

Mike Baird Photography

1. The musculoskeletal consequences of obesity and inactivity are significant and physiatrists have experience prescribing exercise to individuals with physical impairments and managing pain associated with these complaints.

2. During residency physiatrists rotate get formal training in exercise prescription and learn to view it like a drug that has indications, contraindications and a side effect profile.

3. Physiatrists are experienced in team-based medicine and the coordination of patient care across multiple disciplines.

Many internal medicine and family physicians have taken an active public role in prescribing lifestyle modifications. It is not my goal to diminish their abilities – in fact obesity is a complex multifactorial disease that will require an aggressive approach from all angles and people are doing great work from basic science to public health and government levels. I hope to convince you that lifestyle, functional, evolutionary and obesity medicine could be enhanced by the addition of a medical specialist in exercise prescription who holds a lens to look at the patient within the context of their environment, physical limitations and personal health goals.

In essence, I have always wanted to be the doctor on “Biggest Loser”. Not the guy that shows contestants their initial lab tests in an attempt to scare them into outright starvation. But the one comfortable with prescribing a personalized exercise program to an individual with cardiac risk factors, happy to suggest modifications based on new or existing neurologic and/or musculoskeletal injury, equipped with the skills to treat pain flares and looking at new ways to contribute to the body of the literature evaluating how diet, exercise, stress and medications may all interact.

Finally, maybe I stretched the truth a bit with the title your doctor’s famous last words, “lose weight” are changing. Being a healthy weight is important, that evidence hasn’t changed. But how we help patients understand and take control of their health is changing and I hope that referral to a lifestyle medicine specialist, particularly for those that struggle to make meaningful lifestyle modifications, will be one that we seek to make in the future.

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(1) Connaughton AV, Weiler RM, Connaughton DP. Graduating medical students’ exercise prescription competence as perceived by deans and directors of medical education in the United States: implications for Healthy People 2010. Public Health Rep. 2001 May-Jun;116(3):226-234.

(2) Abramson S, Stein J, Schaufele M, Frates E, Rogan S. Personal exercise habits and counseling practices of primary care physicians: a national survey. Clin.J.Sport Med. 2000 Jan;10(1):40-48.

(3) Petrella RJ, FAU – Lattanzio CN, Lattanzio CN, FAU – Overend TJ, Overend TJ. Physical activity counseling and prescription among canadian primary care physicians. – Arch Intern Med.2007 Sep 10;167(16):1774-81.

(4) Laskowski ER. Action on Obesity and Fitness: The Physiatrist’s Role. PM&R 2009 Sept 1:795-797.

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