Let's move our next generation of patients toward healthy behaviors.

Health care professionals in all disciplines who care for adults have the opportunity to improve the health of the next generation. The prevalence of overweight and obesity continues to rise in children and adults around the world. As providers caring for adults, our primary goal is to address the health needs of our patients. However, it is important to recognize that counseling our patients who have children can lead them to adopt model behaviors that will be imitated by their children (and therefore improve the weight status and reduce health risks for their children). Additionally, many patients are more motivated to adopt behavior changes for the sake of their children than for their own health. All of 2012's 11-year-old children may be our adult patients in 10 years - especially if they have already developed weight-related health problems. Anything we do to address childhood obesity is an investment in the health of our patient panels, both now and in the future. While counseling may feel futile at times, there is strong evidence for the power of counseling to shape patient behavior. Counseling adult patients about healthy behaviors will benefit not only our patients today but our patients in the future as well.

Introduction

On February 9, 2010, Michelle Obama, the First Lady of the United States, declared war on childhood obesity. The Let’s Move! Campaign is an ambitious national initiative to eliminate childhood obesity within a generation.

While childhood obesity may seem like a pediatrician or primary care practitioner’s challenge, it is, in fact, a public health problem that providers caring for adults can tackle in their patient encounters as well.1 In fact, several US organizations representing the community of health care providers pledged their support to this initiative when it began two years ago.2–7

The statistics are sobering with one in three adults and half of children in the US being overweight or obese, no matter the health care discipline, we have our work cut out for us.8,9 In the US, up to 50% of obese 6 year olds and 80% of obese 10–14 year olds who have an obese parent will become obese young adults.10 For young children with an obese parent, the risk of being obese as an adult is increased threefold. If both parents are obese, a child’s risk of obesity in adulthood is increased tenfold. Prepregnancy obesity and excess pregnancy weight gain are also associated with childhood obesity and obesity later in life.11 Childhood obesity is an important risk factor for significant adult morbidity and premature mortality, and the importance of addressing it cannot be underestimated.12–14

On a daily basis, we work to encourage our patients to change their health behaviors. We are no strangers to discussing healthy dietary choices and increasing physical activity. For our patients who have children on the way or in their homes, an important part of our counseling efforts should be to remind them that, no matter which behaviors they select, their behaviors impact those children. Either they are modeling behaviors for their children or, in the case of pregnant patients, they are actually programming their children’s weight status for the future.15–17

Studies show that parental modeling plays an important role in the behaviors that children adopt.18–20 It is interesting to note that parents will often change their behaviors to benefit their children’s health, although they may not make the changes based on concerns for their own health.21 An effective counseling strategy may be to emphasize children’s health risks; this may serve as a catalyst for behavior change in the parent, with hope of improved risk profiles and subsequent and parallel behavior changes in their children.22 When our adult patients make those changes for themselves, they can reap the amazing benefits of seeing their behaviors impact the entire family. We as adult providers can also see our efforts impact entire families.

For example, take Mr O, a patient seen in our general internal medicine clinic. At the age of 33 years, Mr O was 22.7 kg overweight and came into our general internal medicine clinic after being referred for an elevated glucose level on a routine blood test. His story in many ways was classic. He had polydipsia, polyuria, and a history of weight gain over the last several years. His initial glycosylated hemoglobin was 11.7%. We knew that we had our work cut out for us. The nemesis of every internist – the never-ending quest for successful lifestyle changes – was staring us in the face.

When we broke the news of his new diagnosis of type 2 diabetes and gathered additional history, we found that Mr O worked as a cook in two restaurants. He worked 90-hour weeks to provide for his family. In his hectic schedule, there was hardly time for exercise, and all of his meals came from the kitchens in which he worked (where fried foods abounded on the menus). While he was very concerned about his own health, Mr O lamented that his children were also gaining too much weight.

We counseled him on lifestyle changes. With regard to diet, we learned that most of the food he ate was what was at work – fattening, fried, and carbohydrate-heavy. We recommended that he restrict his carbohydrates to 3–4 cholesterol units per meal, increase the amount of vegetables in his diet, eat a reasonable amount of low-fat dairy and lean protein, and cut out the deep-fried foods. He said that even though he was surrounded by poor food choices at work, he was motivated by his new diagnosis to eat less carbohydrates and decrease his caloric intake. He cleared out a lot of unhealthy food out of his home, thus affecting how his children and spouse ate too.

With regards to physical activity, we discussed how much exercise he did. True “exercise” was minimal, but he was on his feet all day so he was relatively active. He worked as a short-order cook and had very little time to exercise, though he promised to find more time to do so. We emphasized making specific small steps. He resolved to do more walking, particularly with his family.

After listening to our recommendations on diet and exercise, arranging for an appointment with a dietician, and collecting his prescription for metformin, he said goodbye with a promise to change his lifestyle. We had heard it before, but we hoped for the best.

One month later, Mr O returned for a follow-up visit. To our great surprise, he had already lost 2.7 kg, and his fasting glucose levels were in the normal range. He continued his efforts diligently. Six months later and 22.7 kg lighter, he was off metformin and boasting glycosylated hemoglobin of 5.0%. He was eating moderate portions of healthy foods, and he had increased his physical activity level.

To our delight, he reported that his children replaced fattening and starchy foods with fruits and vegetables and increased their physical activity, modeling his behavior. They began to lose weight as well. His story became well known in his community. Women stopped him on the street and asked what his secret was to managing his weight and beating diabetes. He told them proudly about portion control and increased physical activity, and they listened.

Discussion

Mr O is a wonderful real-life example of the impact one patient’s behavior change can have on his family and his community. And he was spurred to that behavior change by the words of his internist. Counseling patients regarding lifestyle change can be a frustrating and challenging part of an adult health care provider’s job, but we shouldn’t give up. Counseling patients regarding healthy weights, related health risks, and healthy behavior choices is an important part of the work we do and is recommended by clinical guidelines.23–28

Studies have shown that patients with obesity often do not receive counseling regarding their weight in clinical encounters.29,30 Behavior change is essential to improved health for our patients. As we counsel them to adopt healthy behaviors for themselves, we have a phenomenal opportunity to impact their children as well. If you are not a pediatric provider, you may be saying to yourself, “I did not choose pediatrics or family medicine. I chose to care for adults.” Perhaps despite the fact that you selected to care for adults, the job does not end with the patient in front of you. Environmental factors, health literacy, socioeconomic status, and many other factors impact our patients’ ability to adopt recommended behavior changes.31–33 However, the power of counseling in a clinical setting cannot be underestimated.34–36

Our patients have tremendous power to impact the next generation’s health.18,37 As we counsel our patients to change their health behaviors, we have the power to impact the next generation’s health as well. Perhaps an added emphasis on their children’s risk may be an important motivator for behavior change in our patients.

It is also essential to remember that an obese 11-year-old is likely to be overweight or obese as an adult, and in 10 years may be an adult patient. This will especially be true if (s)he has already developed comorbid conditions. An investment in the health of the next generation is also an investment in the health of our future patients. Adult patients do not acquire all of their health risks the day they become 21 years old and enter our care. Health risk accumulates throughout the life course,1 and the health problems of today’s youth and adolescents will be the health problems of our cardiovascular risk-laden young adults in a decade or so.

Reinforcement of these important health messages by health care providers in all disciplines is essential. Patients often have greater concern about their weight or their children’s weights when they have been counseled about weight by a health care provider.38 Whether you are a nurse, pharmacist, obstetrician–gynecologist, pediatrician, adult primary care provider, subspecialist, psychiatrist, physical therapist, dietician, dentist, or other health professional, there is a role for you.39–47

The evidence suggests that we do not do counsel patients often enough or with great skill.48–53 The evidence also suggests that a multidisciplinary strategy is essential to success.54–56 So, let’s counsel our patients about healthy weights and healthy behaviors. Let’s talk to our patients about the impact of their behaviors on their children’s weight and health. In each of our disciplines, let’s teach our trainees to do the same. Ensuring that the next generation of multidisciplinary health care providers is prepared to counsel patients on these issues increases our future patients’ chances of successful behavior change.35,57–65

Let’s try something a little different and see what happens. Let’s move the next generation toward healthier behaviors and reduce the impact of obesity on the health of our patients, their families and our nations. The obesity statistics are staggering. We have a lot of work to do.