Fat, Unfit, Unmotivated: Cardiologist, Heal Thyself

Shelley Wood

October 26, 2011

October 26, 2011 (Vancouver, British Columbia) — Cardiologists would be the first to agree that poor diets, inactivity, and other unhealthy behaviors are key risk factors for cardiovascular disease. But according to Toronto pediatric cardiologist Dr Brian McCrindle (Hospital for Sick Children, Toronto, ON), if physicians want to have more of an impact on their patients' bad habits, they first need to take a good hard look in the mirror.

Speaking here at the Canadian Cardiovascular Congress (CCC) 2011, McCrindle warned physicians his talk would be tiptoeing the thin line between naming and shaming, telling his audience that he hoped to touch on topics that might be "personally uncomfortable" but rarely discussed.

Dr Brian McCrindle

McCrindle's bottom line: cardiologists are not living, eating, and acting like the kind of physicians who can truly motivate patients to improve their own health.

Better physician habits, better patient care

McCrindle started by reviewing studies looking at what factors influenced the likelihood of physicians counseling their patients about healthy behaviors, diet, and weight loss, citing data showing that physicians who had better health habits themselves were more likely to counsel patients about their habits.

Similarly, physicians who exercised regularly were more likely to recommend regular exercise in their patients, and among female doctors, those who practiced a health habit themselves or were currently attempting to improve a health habit were more likely to urge a similar behavior in the patients.

"Clearly what we do influences whether we counsel or not, and how that counseling is perceived by patients influences the effectiveness of that counseling," he said.

Personal misperceptions

But a key issue in this dynamic is physicians' perceptions of themselves. Here, McCrindle showed some startling numbers pointing to the fact that physicians may have a skewed sense of their own suboptimal health.

In one analysis of the Physicians Health Study, 38% of more than 85 000 male physicians had a body-mass index (BMI) over 25 and 6% had a BMI over 30. Likewise, in an analysis from the Nurse's Health Study, 23% of women had a BMI over 25 and 5% had a BMI over 32. In a Swiss survey, just 57% of physicians said they exercised more than three times per month.

More worryingly, physicians seem not to realize just how much they are tipping the scales. In a survey of pediatricians, 40% were overweight based on BMI calculations, yet more than half of these physicians classified themselves as "normal" weight. In another survey of over 3200 Canadian physicians, 91% reported themselves to be in good to excellent health, yet 37% had a BMI between 25 and 30 and 8% had BMIs over 30.

This is important, said McCrindle. While physicians tend to list a lack of patient motivation (or parental support in the case of kids) as a key reason for why they don't counsel patients to be more active and eat better, other studies clearly show that patients are more likely to be receptive to counseling if their physicians are normal weight or if they are open about their own healthy habits.

Hospital hypocrisy

But if physicians frequently serve, even unconsciously, as poor role models for patients, hospitals, too, shoulder some of the blame. In the second part of his talk, McCrindle took hospitals to task for the mixed messages they give patients when they permit fast-food outlets to lease space on site.

Giving some examples from his own institution, McCrindle showed photos that drew chuckles from his audience: an entire wall of soft-drink machines in the hallway leading to the cafeteria, racks of "impulse" snacks at the cafeteria cashier, two whole aisles of chocolate bars, candy, and soft drinks in the in-hospital drug store, and worst of all, a sign directing patients toward fasting lipid tests or toward the in-hospital Tim Hortons and Burger King.

Sick Kids Hospital, says McCrindle, is by no means unique. In one study, he noted, 89% of US hospitals and 50% of Canadian hospitals surveyed had fast-food outlets on site. In another study, most of the cafeterias surveyed carried a high proportion of unhealthy, high-fat, high-sodium, low-nutrient food. The motive, he explained, is typically financial. A separate study showed that 78% of hospitals surveyed kept cafeteria income for the hospital and 39% recuperated all revenues from the fast-food outlets on site. In a striking juxtaposition, hospitals with the lowest-quality food were also the least likely to have programs promoting best health practices to patients and staff.

McCrindle's own hospital, before opting not to renew the contract, made Can$200 000 per year from having a Burger King on site.

The paradox of mixed messaging

McCrindle saved the prickliest part of his talk for the end, telling anecdotes about the untimely deaths of cardiologist colleagues who did not keep their own risk factors in check.

"I can tell you, I will do whatever it takes to not succumb to the same fate, and I worry for some of my colleagues," he said. "Patients should not have to visit their beloved and dedicated healthcare providers in cemeteries."

He also singled out colleagues he'd worked with closely in the past, saying, "the paradox of mixed messaging" was "most vividly hammered home" when he was asked to cochair a summit on childhood obesity coordinated by the AHA and bringing together North American experts in obesity research and policy.

"I gave a talk about healthcare providers and healthcare institutions as role models," McCrindle recalled. "But as I looked out over the audience, half of the men present were obese. Not only that, the very next speaker after me, the leading authority on motivational interviewing for children, was himself obese."

A healthy discomfort

McCrindle shared stories about some of the own changes he'd made in his life — taking up rock climbing, mountaineering, marathon running, and even Iron Man triathlons.

Those kinds of extreme sports will never be on the radar of most physicians, but McCrindle's message was that doctors should at the very least challenge themselves to become more active and speak up about unhealthy aspects of their environments, including their own workplaces.

"And it's important for your patients to know of your actions," he urged. "Share your experiences, achievements, and challenges. Give your personal perspective and admit that you are a person."

And in one of his final pieces of advice, McCrindle acknowledged that some of his words may cut to the quick and that was part of his intention. "Please feel free to be uncomfortable and to take this personally," he said, "because people change when the pain of change is less than the pain of staying the same."

Speaking with heartwire after his talk, McCrindle agreed that the audience here at CCC 2011 seemed to be mostly normal weight — which likely reflects the kind of healthcare professional who is interested in this subject matter. But he thinks cardiologists, generally, are starting to think more about their own health and its impact on their patients. "I think things are getting better — people are more aware of this and starting to discuss it," he said. "You have to have reasonable expectations. One talk is not going to change everybody's opinion, but the more times people talk and think about this, the more likely people are to eventually change."

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