Motivations Behind Lifestyle Changes

Abstract

Lifestyle modification has been demonstrated as a powerful tool in combating the morbidity and mortality of disease. Due to lack of training or education not enough physicians are discussing lifestyle changes with patients. The objective of this study was to determine what influenced participants to make lifestyle changes, and if it was a physician, what was said or done to motivate that decision. Inclusion criterion was participants were enrolled in a program dedicated to dietary modifications. One hundred participants were surveyed. Eighty-eight percent were over the age of 50; 78% were female; 92% were White; and 70% had a bachelor’s degree or higher. Sixty-eight percent felt they had not been educated by their health care provider about nutrition; 41% of participants felt information provided was the most impactful statement; 60% of participants noted that their medical diagnosis had a moderate to significant impact on their decision to make a lifestyle change. This study emphasizes that dietary modifications are not being discussed enough to alter the health decisions of patients in the clinical setting. Furthermore, it is paramount physicians take into account patient motivations when discussing lifestyle changes, as well as the role that proper patient education plays in motivating patients to make a change.

Despite the 1998 National Institutes of Health guidelines, which recommended that physicians counsel overweight and obese patients to lose weight, obesity is still increasing in prevalence and not enough patients are being counseled.

Lifestyle choices contribute to a large percentage of fatalities annually. Heart disease and cancer (599 108) accounted for 23% and 21.3%, respectively, of total US deaths in 2017, both of which have strong links to lifestyle choices. ¹ Additionally, heart disease, cancer, diabetes, and obesity account for 75% of health care costs, but they can often be prevented and their progression can be mitigated or reversed with lifestyle changes. ² Despite the 1998 National Institutes of Health guidelines, which recommended that physicians counsel overweight and obese patients to lose weight, obesity is still increasing in prevalence and not enough patients are being counseled.^3,4 Lifestyle medicine is an emerging and evolving field of care that seeks to address the root causes of disease rather than just treat the symptoms. ⁵ Root causes include what we eat, how we move, the chemicals we choose, and how we deal with stress. Addressing these root causes has been shown to improve health and prevent, and even reverse, disease. One study showed that adhering to intensive lifestyle change, such as a whole food vegetarian diet, aerobic exercise, and smoking cessation, can actually reverse coronary heart disease.^6,7 Additionally, following a vegetarian or vegan diet lowered the risk for type 2 diabetes, and following a low-fat vegan diet improved A1C and lipid levels in patients with type 2 diabetes.^8,9

Several studies have shown the positive effects physicians can have on the lifestyles of their patients.^9-14 When physicians do bring up weight with obese patients, they are more likely to perceive themselves as overweight and attempt to lose weight. ¹⁰ However, another study found that even when physicians did discuss weight, diet, or physical activity with a patient, the patients’ did not report that they remembered having the conversation. This implies that physicians’ approach to counseling patients on lifestyle changes is often not affecting patients the way it could. ¹¹ In another study, it was found that only 20% to 25% of physicians actually counseled their patients and suggested that counseling by physicians should be promoted more. ¹² Additionally, not enough physician-patient conversations that involve diet and lifestyle modifications are being had, because physicians feel unprepared to successfully tackle these conversations. ¹³ It was found that physicians’ use of motivational interviewing techniques and empathy while discussing weight loss increases the likelihood that a patient attempts to lose weight. ¹⁴ A broad range of both verbal and nonverbal communication behaviors are associated with positive health outcomes such as empathy, humor, clarity, health education, and more. ¹⁵ However, few studies have focused on what specifically motivated a patient to change their lifestyle. With an increased correlation between diet and health, we seek to investigate ways in which physicians can motivate nutritional decisions.

Methods

Participants were individuals who currently attend or have attended a lifestyle medicine course taught by a physician assistant board certified in lifestyle medicine by the American College of Lifestyle Medicine. The course was started in June of 2018, and discusses topics such as diabetes, cancer, heart disease, the importance of fiber, weight management, food addiction and behavior change, nutritional myths, and whole-food plant-based diets.

An anonymous, online survey was developed and administered through the web-based survey system Qualtrics. This survey was approved by the Institutional Review Board at Western University of Health Sciences. The survey contained 18 questions, with 7 based on elucidating participant demographics and 11 focused on assessing what influenced their decision to make a lifestyle change. The beginning of the survey contained an informed consent and participants were permitted to skip any questions that they did not feel comfortable answering (see the Appendix for Informed Consent & Survey, available online).

In May 2020, a link to the survey on Qualtrics was distributed with the help of the PA via an email list-serve of all current and past participants. The survey was closed for further submissions in July 2020, with 2 email reminders sent out in the interim through the PA’s list-serve.

Results

Demographics of participants is listed in Table 1.

Table 1.

Demographic Characteristics of the Participants Surveyed.

	N	%
Age (years)
18-19	0	0%
20-29	1	1%
30-39	3	3%
40-49	8	8%
50-59	24	24%
60-69	39	39%
70-80	23	23%
Over 80	2	2%
Gender
Male	22	22%
Female	78	78%
Race
White	91	92%
African American or African American	0	0%
American Indian or Alaska Native	0	0%
Asian	1	1%
Native Hawaiian or Pacific Islander	0	0%
Hispanic/Latino(a)	3	3%
Mixed race	2	2%
Other	2	2%
Highest level of education
Less than high school	0	0%
High school graduate or equivalent (eg, GED)	5	5%
Some college, no degree	13	13%
Associate degree (eg, AA, AS)	12	12%
Bachelor’s degree (eg, BA, BS)	37	37%
Master’s degree (eg, MA, MS, MEd)	26	26%
Professional degree (eg, MD, DDS, DVM)	2	2%
Doctorate (eg, PhD, EdD)	5	5%

Our study found that 81% of participants reported that their health care provider (HCP) spoke to them about dietary modifications; however, 68% of participants felt they had not been properly educated about nutrition by their HCP. Thirty-eight percent had never discussed diet changes with their HCP, while 38% had only discussed diet changes 1 or 2 times. Of those that discussed diet changes with their HCP, 59% never mentioned a whole-food plant-based diet. When asked about the influence of various factors on their dietary changes, 56% stated that HCP had no to moderate influence, 53% stated that family and friends had a moderate to significant influence, and 60% stated that their medical diagnosis had a moderate to significant influence. When asked about impactful statements made by their HCP, 41% noted the information provided, 34% found concern over long-term health to be impactful, 31% were impacted by how the provider spoke to them, and 30% were impacted by shared personal benefit. When asked about the most impactful statement, 21% found that the information provided was the most impactful (Figure 1).

Figure 1.

The most impactful statements made by the health care provided (HCP)

Discussion

Despite the fact that improved nutrition is considered one of the most important methods for combating disease, ¹⁶ our study further demonstrated that physicians still are not talking about nutrition. This observation appears to reflect the current literature on the lack of nutrition counseling provided by physicians, with fewer than 13.5% of today’s physicians feeling adequately trained to discuss nutrition with their patients, the majority of which devote less than 3 minutes to such discussions. ¹⁷ Of those who did discuss nutrition with their patients, whole-food plant-based was rarely mentioned despite the overwhelming evidence a whole-food plant-based diet can improve health outcomes in the right patient populations.^18-20 This observation only further highlights the paucity of proper nutrition counseling and lack of proper physician education. While many programs to help bridge this gap in knowledge currently exist, ²¹ there still appears to be an insufficient amount of proper training in place that would give practicing physicians the confidence to initiate discussion on diet and nutrition. Modification of the medical curriculum offers itself as one such solution; however, a majority of medical schools still fail to adequately incorporate nutrition in their curriculum.^22,23 Our study clearly indicates that there is still an opportunity to further expand discussion on how best to train physicians to engage in meaningful conversations with their patients on the role of diet in their health.

The motivation underlying people’s decision to change their behavior is multifaceted. Every participant ranked HCP and family/friends as having some impact on their decision to alter their diet, with the HCP having the lowest impact out of all 3 categories. It is well understood that a strong physician-patient relationship is necessary in order to achieve maximal health outcomes. ²⁴ However, as our study indicates, it is paramount to take into consideration the role of an individual’s community on their health. Prior studies have demonstrated the significant impact that partners and other members of the individuals’ social circle have on diet changes and adherence to those changes.^25,26 Therefore, it is paramount that the physician consider these individuals as an integral part of the health care team, when developing a lifestyle change strategy with their patients. In addition to the role of the HCP and family/friends on lifestyle change, our study indicated that the patient’s own diagnosis had the greatest impact on a participant’s motivation for change. Consistent with current literature, the perceived consequences associated with someone’s medical diagnosis provides an important intrinsic motivator for change.^27,28 Therefore, it is imperative that physicians adequately communicate with their patient’s the nature of the disease as this information is often taken into consideration in the individual’s decision to move toward a lifestyle change.

The unique role of the physician in helping motivate lifestyle change cannot be overstated. As such, it is necessary that physicians have the skills necessary to effectively communicate and motivate their patients to make lifestyle changes. Motivational interview is one such method that has been shown to successfully motivate patients to make changes to their diet and exercise habits. ²⁹ Our study highlights statements that can be utilized within the motivational interview framework. Information provided had the greatest impact, highlighting the importance of patient education. This is consistent with current literature that finds patient education strongly contributes to behavior and lifestyle change. ³⁰ Therefore, it is important for physicians to properly educate their patients when counseling their patient to change in lifestyle or behavior. This education should not only include strategies for change and resources but should also highlight the nature and severity of the disease, which our study found plays an integral role in an individual’s motivation to change their lifestyle.

There are several limitations to consider with our data. The data were collected from self-reported surveys. Thus, we were unable to control for respondent bias. In addition, the demographics of our respondents reflects those of rural Oregon; however, these findings may not be generalizable to a more diverse patient population. Finally, our small sample size in this preliminary study restricts large-scale conclusions and generalizations, but it still shows possible patterns that warrant further investigation and consideration. While we cannot show statistical significances due to the small sample size, the findings are noticeable and may help expose obstacles facing the rural population.

Conclusion

While it has been established that nutrition and lifestyle change have a positive impact on health outcomes, our pilot study found that a minority of physicians are having conversations with their patients. This highlights the need for further discussion on how to best educate and motivate physicians to have discussions with the patients regarding nutrition and lifestyle changes. When considering the best method to counsel patients, our study found that it is important for the HCP to consider the impact of a patient’s medical diagnosis and contribution of family and friends in a patient’s decision to make a lifestyle change. Furthermore, we found that when counseling patients it is important for physicians to provide the proper information for their patient to make an educated decision on modifying their lifestyle. However, further research is needed to determine the role of the physician in patient adherence to lifestyle changes.