“Don’t make it about weight loss,” Barbell Medicine Ep. #194: September 2022 Research Review

Imagine two scenarios: in one, a patient goes to the doctor and exhibits high blood pressure, and the doctor prescribes a medication and says in passing, “oh, and it wouldn’t hurt to start exercising.” In the second scenario, the doctor sits the patient down, discusses the pros and cons of starting medication right away and then asks them about their physical activity level, barriers to increasing activity, and makes a specific plan for them to begin a walking program in addition to taking their meds. Which one would you expect to bring greater outcomes?

In what seems a bit like a “well, duh” (but I’m grateful for the evidence anyway) conclusion, a new study discussed this week on Barbell Medicine demonstrates an increased adherence to physical activity recommendations when they are matched with “behavioral counseling.” What I think is not as apparent, but I consider a fantastic conclusion brought by Dr. Baraki, is that the relative success of the intervention compared to the benefits of the medication is also higher. Meaning: a highly successful medication may prevent say 1 in 50 people from having a heart attack down the road, but, according to this analysis, the exercise with behavioral counseling intervention could help 1 in 12 people in becoming active enough to have protective effects. Maybe I missed some nuance in this discussion (I’m not a doctor, after all), but the gist as I understood it was to encourage physicians to see the relative efficacy of this work and to help them to not get discouraged at the other 11 out of 12 folks who maybe struggled to take action after getting that support.

They begin the episode with a welcome conversation discussing the study itself, its findings (improved exercise adherence and low risk), and some of the questions left unanswered by the research (what does effective behavioral counseling look like?). I really appreciate when the discussion turns to unanswered questions, as I’ve witnessed some pretty wide-ranging physical activity recommendations from my own doctors over the years. The term “behavioral counseling” can be pretty diverse in its practical application, from a brief comment to a detailed discussion.

The docs point out that there are evidence-based practices in behavioral counseling, including motivational interviewing and providing specific exercise “prescriptions” with clear definitions of the movement, duration, frequency and desired outcome. Anything we can do to get away from the “move more” vagaries would be a welcome change.

And although it isn’t addressed directly, I think this discussion doesn’t ignore the fact that weight stigma changes how doctors interact with patients when it comes to physical activity. The docs recommend that physicians make it about movement and whatever health risk factor they’re addressing directly, not about weight loss. Weight and weight loss discussions can be so fraught and likely to dissuade a lot of folks from being able to take meaningful action. It can also feel impossible for folks whose only experiences with weight loss are crash diets and other failed strategies. I know that bringing up weight loss is a quick way for a doctor to lose some trust from me. I’ve also had doctors “prescribe” activity without first asking me what I do on a regular basis. And even when they do, I believe that weight stigma plays a role in how that conversation goes, too. How many doctors have I had treat me with skepticism that I lift, especially when my bodyweight is on the higher end of my normal range?

Which brings me to a few questions–are you open to discussing your activity choices with your doctor? What barriers or challenges have you encountered in those discussions, and what could they do better to have a more effective conversation with you? For that matter, have you had a wonderous success discussing an exercise “prescription” with a physician? What made it work for you? I’d love to hear from you in the comments below.


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