Prescribing Lifestyle Modifications - Annals of Internal Medicine: Fresh Look Blog


Wednesday, April 24, 2019

Prescribing Lifestyle Modifications

I wish it were possible to write “time” on a prescription pad—time to prepare meals, time to see their therapist, time to exercise, time away from work, time with their loved one.  On another prescription pad I would write “motivation” and tell patients to use the two prescriptions concurrently.  Obviously, I can’t prescribe time or motivation specifically (who knows, maybe someday?), but my EMR does allow me to have a drop-down menu for lifestyle modifications. Unfortunately, these often seem equally unfeasible for some patients in practice.

For example, many of my patients have diabetes, and even more struggle with losing weight.  There are countless data on pharmaceuticals but not as many on lifestyle modifications themselves.  In addition, “lifestyle modifications” is a catch-all term that I (and my patients) find frustrating.  What does that mean?  What concrete advice was provided?

Articles like this one in Annals of Internal Medicine (1) are very helpful to me.  In an era of keto and trend diets, I need some backup from research to present best options for patients. This article provides an interesting take on lower-carbohydrate diets and provides some reasoning, albeit not clear reasoning, as well.  The study tries to answer the question, “In adults who have lost 12% body weight, what are the effects of diets varying in carbohydrate-to-fat ratio on energy expenditure (EE) during weight-loss maintenance?”  Patients were divided into groups with high, moderate, and low carb-to-fat ratios.  The low-carb group had higher energy expenditure without changing physical activity.   

However, I found one particular line the most interesting: “[A]ll meals were provided.” There was no running to the grocery store after work, no meal prep, no thought needed on the recipes, no one worrying about the electric bill.  Participants ate the meals that were prepared for them. 

There are numerous nuanced reasons why our weight as a society has increased.  There are the obvious causes—working more, sitting more, exercising less, sedentary lifestyles.  But there are more complex reasons as well—from food access to other life stressors to perceptions of body image.  Some people have said to me, “I’d rather spend all 3 hours from when I get home until my kids go to sleep to be with them instead of being at a gym.”  It is hard for anyone to argue with that logic.  When life is busy and time is limited, wouldn’t you want to spend it with your loved ones?  The idea that investment in health now allows for better health in the future is a hard idea to sell.  It is often easier to think about life in the short term than in the long term. 

I find that I am most helpful in the weight loss journey for patients when I can give concrete plans.  “See the nutritionist at X center on Y date.” “Here is a diet plan I use for patients that has specific meal ideas and recipes.” “Here is a workout you should do 3 to 4 times per week.” I actually find these direct instructions and frequent check-ins to be helpful for patients. 

I often wish I could prescribe fixed, healthy meals to my patients.  I would like to see more research on what happens when these food decisions were made for the patients like they are in these studies.  What effects would that have? 

Research on diets are extremely important in helping us better understand food and its effect on weight.  But I also think we need research on what happens when life is made a bit simpler for people—does that affect weight, too?

I am still early in my career in medicine.  I hope I get to be a doctor in a time where “lifestyle modifications” are prescribed interventions that bring true meaningful improvement to patients’ lives.

  1. Kahan S. ACP Journal Club. During weight-loss maintenance, energy expenditure was higher with lower-carbohydrate diets. Ann Intern Med. 2019;170:JC31. [PMID: 30884501] doi:10.7326/ACPJ201903190-031

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