by Beth Shepard   Beth's profile on LinkedIn  

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My brother-in-law, David, recently underwent a complete physical; it had been several years. His regular doctor was booked out for several months, so my sister scheduled David’s appointment with another provider… someone he hadn’t seen before.

This provider entered the exam room and told David his blood pressure and labs looked good. And then she hit him with this: “I’m not going to beat around the bush; you’re fat. David was stunned. He knew he could stand to exercise more and lose some weight, but this remark was terribly blunt and unkind. She proceeded to ask him what he weighed on graduating from high school (~30 years ago). “I want you to go to the gym, do cardio, and don’t do strength training,” she went on. “Come back in 3 months; by then you should be 30 pounds lighter.”

As David told me his story, his irritation and defensiveness were easy to see. Half-kidding, he said, “Go to a gym? Lose 30 pounds in 3 months? Forget that; I’ll show her — I’ll gain 6 pounds instead.” Later, he stated he would never go back to that provider.

A Missed Opportunity

Health behaviors are personal. Changing them is anything but easy, as discussed in Small Steps or Giant Leaps — What Works Best for Health Behavior Change?

Nobody wants to be treated like a misbehaving child or bulldozed into attempting a change they’re not ready for. The provider may have had good intentions, but her message left him feeling patronized, resentful, and unlikely to make a change anytime soon.

To say I’m disappointed by David’s experience is putting it lightly. As clinicians, employee wellness leaders, registered dietitians, fitness professionals, coaches, and others, we all have a genuine desire to help people. Whatever our specific role, there’s an understanding — and an expectation — that we all work together and do our best for the good of the patient. When somebody drops the ball, and the patient suffers, our collective effectiveness takes a hit.

Many excellent professionals are out there, doing the right things to promote behavior change. But because David’s experience isn’t all that unusual, our industry as well as employers and HR managers have cause for concern. Our carefully constructed wellness programs, integrated services, and communications direct clients to seek regular preventive care. But what if, when they show up for office visits, they’re told, “You’re fat; do this, do that.” Think about the ramifications; they may:


  • Tell a lot of people about the negative experience — including friends, family, and coworkers; this is not helpful PR
  • Be less inclined to participate in wellness offerings geared toward behavior change, because the provider threatened their sense of autonomy
  • See you as a less-credible source of information on health and well-being, because it was your program that said getting a physical was such a great idea
  • Be more reluctant to seek preventive care, because who wants to go back for more of that kind of treatment?

What to Do — HR and Wellness Pros

As large purchasers of healthcare services, employers are gaining ground in influencing quality of care. A few ideas:


  • Talk with your network provider reps. How is quality of care measured? Do providers receive any training or tools in behavior change skills from the health plan or other organization? If not, request a program; offer behavior change research and resources. See if your organization can link this to their performance analysis.
  • Communicate to employees and dependents the importance of choosing the right provider — and how to take an active role in healthcare visits. Many people think they have to accept whatever a doctor is dishing out and aren’t aware they can change providers.
  • Prepare your population to talk more effectively with healthcare professionals.
  • Encourage people to give specific feedback to providers through clinic surveys, provider reviews or ratings on the health plan website, or by speaking directly with the provider or clinical manager.

What to Do — Health Care Providers

It’s no secret that unhealthy lifestyles form the basis for many noncommunicable diseases. As evidenced by research on tobacco and physical activity interventions, providers can have a profound influence on a patient’s decision to change. Here are a few tips and resources to share for incorporating behavior change counseling into clinical practice:


  • Review the 5-A approach: Assess, Advise, Agree, Assist, and Arrange; this is the simple, brief, clinical approach to behavior change adopted by the US Preventive Services Task Force.
  • Recognize that patients are the experts on their readiness to change, short-term and long-term goals, a realistic place to start, barriers to overcome, and how best to make change work in the context of their lives. In a behavior change conversation, the patient should do most of the talking.
  • Establish rapport and trust before launching a conversation about behavior change.
  • Ask if the patient has considered making any changes. If not, ask for permission to address concerns. “Are you interested in talking about lifestyle changes that could make a big difference in your health — and your energy level?” Keep it positive, relevant, and focused on immediate rewards. If the answer is no, remind the patient to bring it up when they’re ready.
  • Track physical activity as a vital sign. Asking about exercise opens an important conversation, and reinforces the message that being active is vitally important. A Kaiser Permanente study linked this to modest weight loss in overweight patients and better blood glucose control in those with diabetes.
  • Keep a list of community wellness resources for easy referral. This could include YMCAs or other fitness centers, parks and recreation programs, certified fitness professionals, certified wellness coaches, registered dietitians, and behavioral health providers.
  • Seek out additional training as needed to boost behavior change skills.

Recommended Resources

The Institute of Lifestyle Medicine
American College of Lifestyle Medicine
Wellcoaches® Coaching Psychology Manual — Lippincott Williams & Wilkins, 2010
ACSM’s Exercise is Medicine™— A Clinician’s Guide to Exercise Prescription — Lippincott Williams & Wilkins, 2009.

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