Disease diagnosis often prompts patients to make healthier choices
■ Experts would like to see strategies developed to make it easier for physicians to make the most of this opportunity.
By Victoria Stagg Elliott — Posted Feb. 23, 2009
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Bad medical news makes middle-aged and elderly patients more likely to quit smoking and lose weight, according to a study in the Feb. 9 Archives of Internal Medicine.
"They may be more motivated to change. ... This idea of secondary prevention merits another look as far as where it fits with the care that's provided to patients," said Patricia Keenan, PhD, author and assistant professor in the Yale University School of Public Health in Connecticut.
Dr. Keenan analyzed survey data from the Health and Retirement Study on 20,221 patients who were overweight or obese and 7,764 who smoked. Those who within the past year had received a diagnosis of stroke, cancer, a lung condition, heart disease or diabetes were 3.2 times more likely to quit smoking than those who had not received such information. Those diagnosed with more than one condition were six times more likely to quit.
Those who were overweight and were diagnosed with a lung condition, heart disease or diabetes reduced their body mass index by an average of 0.35 units. When only data on those with diabetes was analyzed, BMI decreased an average of 0.6 units.
It's unclear why this happens, although theories abound. Some of the weight change may be due to the nature of an illness like diabetes, but experts also suspect physicians may be more likely to counsel on lifestyle issues when delivering a diagnosis or in the course of care for chronic conditions. Patients may be more ready to change, or all of these factors may be at work.
"Most people who suffer a health setback will be more receptive to advice from a health care practitioner to improve him or herself," said Samuel Grief, MD, associate professor of clinical family medicine at the University of Illinois, Chicago. "Doctors have a wonderful opportunity to address health care issues."
This idea may be particularly true for patients who thought they were well. This study found those who rated their health as excellent or very good were 32% more likely to quit smoking.
"A lot of smokers are in real denial and think, 'These things are not going to happen to me.' The diagnosis kills that excuse," said Steven Schroeder, MD, distinguished professor of health and health care and director of the Smoking Cessation Leadership Center at the University of California, San Francisco.
Although the reason for this phenomenon is unknown, the authors of the paper and its accompanying editorial suggest these data indicate that secondary prevention is probably a good investment of health care dollars. They urge that ways be found to make it more likely patients receive such counseling timed to the diagnosis. Several studies have found the percentage of physicians who do so is low, and that incorporating secondary prevention presents significant challenges, particularly with regard to weight loss. Physician advice to stop smoking has proven to be effective, but the only interventions shown to work for obesity tend to be fairly time- and resource-intensive.
"There are very low-cost smoking-cessation resources. What can a physician do to help link patients to weight-loss services? They are not covered by health insurance. ... Patients may be more motivated, but I'm not sure if physicians have enough resources," said Sherry Pagoto, PhD, lead author on the editorial and assistant professor at the University of Massachusetts Medical School.
In order to address this gap, researchers are working to make weight-loss interventions more feasible in the primary care setting. A study in the Feb. 17 Annals of Internal Medicine found that obese patients participating in a weight-loss program that included sibutramine and frequent counseling lost the same amount of weight whether they talked to a dietician over the phone or in person. The authors suggest that the ability to reduce face-to-face interactions may improve the cost-effectiveness of obesity treatment.
Public health agencies and medical societies have long struggled to devise ways to reduce the number of people who smoke or who carry excess weight. The American Medical Association, which has numerous policies addressing both issues, last year launched AMA Healthier Life Steps, an online tool kit to help initiate discussions between physicians and patients about healthy lifestyle choices. Within the next few months a Spanish-language version will be released, as will a coding tip sheet to increase the likelihood that physicians will be paid for counseling on these issues.