Lost in Translation
Evidence-Based Interventions in Physical Activity and Nutrition
Phillip B. Sparling, EdD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 33 - NO. 8 - AUGUST 2021
From an ecological perspective, obesity can be understood as an adaptation to a complex modern society.1 Healthy lifestyle recommendations on how much physical activity to get and what and how much to eat continue to be updated and refined, most recently by the US Department of Health and Human Services and the Department of Agriculture in the Dietary Guidelines for Americans 2021.2 These new insights and interpretations build on fundamental principles and recommendations that have been in place for many years,3 yet sedentary behavior and overeating are more pervasive than ever. We see these problems firsthand every day, both as clinicians and as concerned citizens.
Helping Patients Help Themselves
Despite occasional successes, healthcare professionals are often frustrated with efforts to help patients help themselves. Many Americans mistakenly believe that scientists can solve nearly any problem, including medical maladies. Even with continued advances in genomics and molecular medicine, the discovery of a truly effective, safe, and affordable drug for obesity prevention is improbable. The best solution available is behavior change. The mantra remains the same: Control and treatment of conditions caused by poor eating habits and physical inactivity require changes in lifestyle. These include decreasing food portion sizes and saturated fat intake, substituting fruits and vegetables for calorie-dense foods, and increasing physical activity. Abundant evidence demonstrates that these behavior changes are beneficial in combating obesity and comorbidities, including metabolic syndrome, diabetes, cardiovascular disease, and cancer.4,5
Yet, without widespread political and social mandates, it will remain difficult to create an enabling environment for lifestyle changes at the individual level. Thankfully, small coalitions of private industry, government agencies, and communities are organizing to address this problem. They are examining ways to enact environmental and policy changes that promote healthy eating and physical activity. Realistically, such changes will take years to develop and implement on a broad scale.
Not surprisingly, clinicians struggle to be proactive with patients (and themselves) in the current health-compromising culture. Evidence-based strategies for patient counseling on physical activity, healthy eating, and weight control are available but not widely implemented. Claude Lenfant, MD, a former director of the National Heart, Lung, and Blood Institute at the National Institutes of Health (NIH), eloquently describes this "lost in translation" phenomenon6 and suggests ways to bridge the gap. The key point is that translation is not a simple process that will take care of itself.
Translating Evidence Into Clinical Practice
Translation refers to the various steps required to effectively disseminate and implement new evidence from biomedical and behavioral research into real-world clinical practice. Recently, the NIH committed resources to the study of translation. This is a big step forward. Topics being investigated include assessing the gap between knowledge of interventions and implementation, understanding reasons for gaps in application, and evaluating strategies to improve delivery and outcome. A case in point is that the need for practical clinical trials (ie, study trials that are more relevant to clinicians and decision-makers) is being recognized, discussed, and acted upon.7 Translational research, particularly in the behavioral sciences, will lead to better methods on how to implement and integrate practice-based counseling and treatments.
In the meantime, a number of carefully developed guides are available. For example, the practical guide on treating overweight and obesity from the NIH,8 a Journal of the American Medical Association article9 on practice-based weight loss counseling, and an article10 from THE PHYSICIAN AND SPORTSMEDICINE on motivating patients toward weight loss are excellent places to start. Moreover, the Guide to Clinical Preventive Services11 and the Guide to Community Preventive Services12 are authoritative resources for practitioners in clinical medicine and public health.
The Guide to Clinical Preventive Services11 was developed by the US Preventive Services Task Force and overseen by the Agency for Healthcare Research and Quality. The task force—an independent panel of experts in primary care, prevention, and evidence-based medicine—systematically reviewed the evidence of effectiveness for clinical preventive services. The resulting recommended preventive measures are organized into three categories: screening, counseling, and chemoprevention. Relevant sections include screening for obesity and counseling for physical activity and healthy diet. This publication is the gold standard for clinical preventive services.
A complementary resource is the Guide to Community Preventive Services,12 which is supported by the Centers for Disease Control and Prevention. This guide was also developed by an independent group of experts, the Task Force on Community Preventive Services. This task force oversees the systematic evaluation of community, population, and healthcare system strategies on a variety of public health and health promotion topics. Physical activity recommendations are currently available, and obesity treatment recommendations are scheduled to be released in 2021. In addition to primary care, the task force's membership provides perspectives from state and local health departments, managed care, behavioral and social sciences, mental health, communications sciences, epidemiology, decision and cost-effectiveness analysis, and public policy.
Rethinking Our Approach
As practitioners committed to preventive medicine, it's time to rethink our approach to helping patients make healthy lifestyle choices. Let's have our healthcare teams review and discuss the most relevant and salient recommendations on physical activity and nutrition, with an eye toward identifying, refining, or expanding practice-based strategies. The aim is to improve how we communicate with patients, striving for messages that are clear, specific, and appropriately emphasized. Admittedly, notable barriers exist, including competing health priorities, time constraints, and financial factors. Yet, ways can be found to work within systems. Many tasks can be shifted from physicians to others among the healthcare team such as nurses, physician assistants, nutritionists, exercise specialists, psychologists, and health educators.
A final suggestion is to assess impact (ie, measured changes) on weight control, healthy eating (eg, fruit and vegetable intake), physical activity (eg, frequency and duration of weekly activity), and overall health (eg, quality of life). This can be done with standardized brief surveys. It's essential to know what is working and what is not. Let's use monitoring and feedback to improve strategies and efficiency of delivery and to accumulate evidence that supports the practice time spent on translation efforts.
For a variety of reasons, application of fundamental knowledge in clinical practice is not what it should be. Translational research will help us improve the way we communicate lifestyle messages to patients. As medical practitioners, you will be invited to partner on translational projects and practical clinical trials. Your input will be crucial in determining the questions to be studied. In the meantime, solid recommendations are on the shelf waiting to be used. Let's continue to forge ahead, encourage colleagues to join us, assess what we are doing now, study the latest recommendations, and support specialized training for your healthcare team.
Our charge is to advance preventive clinical medicine and further public health efforts by better incorporating (translating) physical activity and nutrition recommendations into real-world obesity and chronic disease prevention and control practices. Many patients will respond positively in word and deed to concern, guidance, and follow-up from healthcare professionals. This is a call to reassess our efforts for a most worthy cause—enabling patients to have a better quality of life.
Dr Sparling is a professor and codirector of the exercise physiology laboratory in the School of Applied Physiology at Georgia Institute of Technology in Atlanta. Address correspondence to Phillip B. Sparling, EdD, 1120 Clifton Rd, Atlanta, GA 30307; e-mail to [email protected].
Disclosure information: Dr Sparling discloses no significant relationship with any manufacturer of any commercial product mentioned in this article. No drug is mentioned in this article for an unlabeled use.