VOL: 102, ISSUE: 17, PAGE NO: 45
Dympna Pearson, RD, is a consultant dietitian and a behaviour change trainerA low-calorie diet, physical activity and behaviour therapy are the most effective methods for weight loss and for ...
A low-calorie diet, physical activity and behaviour therapy are the most effective methods for weight loss and for maintaining it (NIH, 1998). Because eating and physical activity are behavioural activities, a behavioural approach needs to be taken to any weight loss intervention.
According to the Health Development Agency (2003) the main principles of a behavioural approach include:
- Modifying current behaviour patterns;
- Taking an adaptive approach to learning;
- Having a collaborative relationship between client and practitioner.
Healthcare practitioners must address their own attitude towards people who are overweight. Research shows that they can be judgemental and reflect society's prejudice and discrimination towards the obese (WHO, 2000). It is negative attitudes such as this that may contribute towards an overweight person being reluctant to ask for help (WHO, 2000).
There are many reasons why people become overweight; these include lifestyle, but metabolic and genetic factors also contribute to the development of obesity. The circumstances in which a person lives may also make it difficult to manage weight-gain.
There are a number of health behaviour models that contribute to our understanding of human behaviour in relation to health. The Stages of Change model (Prochaska and DiClemente, 1986) is frequently applied in the field of weight management. This involves five stages:
This model helps us to understand the process people go through to make permanent lifestyle changes, but it cannot be applied in a rigid manner. People may move from one stage to another, even during the course of a consultation.
Being client-centred is an essential component of a behavioural approach. This means forming a therapeutic helping relationship that is based on trust, acceptance and expressed empathy, so that both patient and practitioner are working together in a respectful and collaborative partnership.
It is easy to assume that people do not want to change when they are struggling with their weight and appear as if they do not to want to take responsibility. It is vital, therefore, that practitioners try to understand what is happening in this situation and to explore the difficulties patients are experiencing, at the same time recognising their right to make their own decisions about change.
Research shows that if practitioners believe that somebody cannot change, this will be borne out, regardless of what is said in the consultation. A skilled practitioner can greatly influence motivation and change (Miller and Rollnick, 2002).
The single most important factor that influences change is a practitioner who has good interpersonal skills (Najavits and Weiss, 1994). The health practitioner's way of working strongly influences the outcomes of interventions (Miller and Rollnick, 2002). When Stewart et al (1995) looked at 20 different studies (11 randomised controlled trials and nine good observational studies) comparing outcomes with communication skills, 16 showed a positive and significant relationship between communication and patient health outcomes. The authors conclude that 'good communication is good evidence-based medicine'.
Health professionals often express concerns about talking to patients about their weight. Listening skills are essential for a health practitioner helping someone with a weight problem. This will involve using open questions, paraphrasing, reflecting feelings and summarising what has been discussed (Miller and Rollnick, 2002. People who are struggling with their weight need to feel heard and understood. Their difficulties need to be acknowledged and they need to have a supportive helper to explore the way forward.
The role of the practitioner is to explore patients' difficulties and help them find ways to overcome them. To do this they need to tap into the patients' intrinsic motivation and elicit their own ideas on what will work best for them. These ideas may be supported by information from the practitioner on evidence-based approaches of what works well for others.
A number of strategies can be adapted from motivational interviewing and cognitive behavioural therapy. No one strategy has been found to be superior (Foreyt et al, 2001). What is important is that the approach is tailored to the individual.
It is important that practitioners are appropriately trained in the application of the necessary behaviour change skills. Some of these are discussed below.
Raising the issue of weight This can usually be linked to a health concern. For example: 'Are you aware that losing weight would help lower your blood pressure?'
This needs to be carried out in a collaborative way, establishing if weight loss is an important priority, what influences this, and whether the patient feels able to make the necessary changes. This may lead to exploring difficulties with the patient and how to overcome them. Great care needs to be taken to avoid interrogating the patient. Questions such as 'How important is losing weight to you', and 'What are the obstacles?' can alienate patients if they are not asked in a sensitive manner and without reflecting back the patient's response.
Being ready or motivated to make dietary or activity changes is not an all or nothing state. Weight management requires lifelong commitment, therefore attempting to assess whether someone is 'ready or not' can be unhelpful if it involves the health professional making a decision on behalf of the patient. It is more helpful to have a discussion about what weight loss means to the individual and what aspects of change she/he might be willing to address.
This needs to be a two-way process, with practitioners eliciting what patients know and offering information in a neutral way, and checking how they understand this information.
Eliciting information about current behaviours
People are often reluctant or unable to give very detailed accounts of current behaviours. It is more productive to ask for an overall view of how eating and activity fit into the individual's life.
This is an invaluable tool for raising awareness but should not be used by the practitioner to 'check up' on the patient. It needs to be carefully set up to record behaviour that is being changed and the task should be kept as simple as possible, as diary- keeping is hard work. Self-monitoring inevitably leads to problem-solving.
An effective change plan will help facilitate goal-setting. This consists of a written record of:
- The overall target;
- Specific goals;
- How the goals are going to be achieved;
- What difficulties might arise and how to overcome them.
The plan should also include sources of support, rewards for changing behaviour and how and when monitoring and review will happen.
This is often helpful when patients are struggling with changing their eating and physical activity. It is useful to take a step back and explore what are the good things and the not so good things about making the changes, as well as considering what would be good and not so good if they did not change.
Practical application of a behavioural approach
Once weight has been identified as a health concern, the practitioner has a responsibility to ensure that the patient is aware of the benefits that can be achieved from even small amounts of weight loss. A weight loss of 5-10% has been shown to achieve clinically significant benefits (Scottish Intercollegiate Guidelines Network, 1996). In practice most patients find it easier to think of that first half stone.
Once the patient expresses an interest, exploring the individual's readiness/motivation can help build a picture of what losing weight might mean to the individual and what the difficulties might be. This helps to identify what type of intervention would be most useful.
As part of the assessment it is important to collect clinical data, including height, weight, body mass index, waist measurement, lipid profile, blood glucose levels and thyroid function. A history of the patient's weight and previous attempts at losing weight should also be obtained.
It is important to acknowledge any previous attempts at weight loss and to convey a sense of optimism while, at the same time, helping the client set realistic goals. Discussing support, rewards, monitoring and reviewing progress are all part of a behavioural approach.
A behavioural consultation should have a clear structure, where the practitioner guides the patient through a collaborative assessment and then moves on to consider the options, which must be tailored to the individual.
Obesity is a chronic, complex disease requiring lifelong management. It needs to be recognised that patients need support not only for the weight-loss phase of treatment, but also for long-term weight maintenance. Primary care staff are ideally placed to offer effective and regular support, provided they have been trained with the appropriate skills. Restrictions of time and of resources need to be matched with realistic expectations of what can be achieved.