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To Change Patient Behavior, Change How You Talk To Them

According to Marshall Becker, PhD, MPH, a one-time professor of mine and prime mover behind the Health Belief Model (HBM), four things must be in place for health behavior change to occur. I am paraphrasing here: 

  1. A person has to know that they have a particular health condition.
  2. A person has to believe that having said health condition is bad.
  3. A person must perceive the benefits of behavior change to outweigh the difficulties of behavior change.
  4. There must be a “call to action” to spark the change.

Absent any one of these steps and the likelihood that behavior change will occur is diminished.

Now consider the problem of obesity and behavior change.

A series of recent Harris Polls looked at people’s perceptions and experiences regarding their weight. The polls, which confirm similar findings from numerous medical journals, found that:

  • 39% of morbidly obese people (BMI >40) think they are overweight but not obese.
  • 70% of obese people (BMI >30) believe they are merely overweight.
  • 61% of “technically obese” adults had never been told by a health care professional that they were obese…or that they needed to do anything about their weight.

Following the logic of the Health Belief Model, several critical behavior change “prerequisites” are missing. First, many obese and overweight people do not believe they have a real problem with their weight. Other people are obese — not them. Sure they know they need to lose weight. Many are probably trying on their own.

Second, since their physicians hasn’t told them they are obese, there is no reason for them to believe they have a problem or that carrying a few extra pounds poses as serious health risk.

At this point, according to the HBM, the likelihood of behavior change falters. There’s no reason for the patient to seriously consider the barriers or benefits to significant weight loss.

Poor physician-patient communication enables obesity…and probably many other chronic conditions:

The evidence shows that patients who receive physician counseling about weight loss are up to 2 times more likely to report that they are currently trying to lose weight.  Yet such conversations reportedly do not occur in some two-thirds of physician visits by obese patients.


From the physician’s perspective, key barriers to weight loss counseling are self-perceived low competence in treating obesity, lack of treatment effectiveness, and poor patient motivation. Don’t underestimate the importance of physician attitudes toward obese patients. One study found that physician believed that 40% of their obese patients were capable of achieving a normal weight, but that most patients were not sufficiently motivated to lose the weight.

The therapeutic value of talking to patients

Physicians have more a lot more influence with patients than they seem to give themselves credit for. If patients have a health problem, they expect their physician to tell them.

One has to wonder how many patients suffer needlessly from obesity, diabetes, heart disease and so on simply because their physicians did not take the time to impress upon them:

  1. The fact that they have a condition.
  2. That having the condition is serious.
  3. That there are treatment options.
  4. Here are the benefits and challenges.
  5. Together we can solve the problem.

It certainly makes me wonder.


Befort, C., et. al., “Weight-Related Perceptions Among Patients and Physicians: How Well do Physicians Judge Patients’ Motivation to Lose Weight?” Journal of General Internal Medicine. 2006 October; 21(10): 1086–1090.

Greiner, K., et. al., “Discussing Weight with Obese Primary Care Patients: Physician and Patient Perceptions.” Journal of General Internal Medicine. 2008 May; 23(5): 581–587.

Overweight? Obese? Or Normal Weight? Americans Have A Hard Time Gauging Their Weight.”

*This blog post was originally published at Mind The Gap*

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