Whether they want to lose a few pounds that were added over the holidays or develop a more comprehensive weight-loss goal, many of your patients will resolve to lose weight in the new year. During the next few weeks, your patients may be more receptive to weight-loss counseling than at any other time of the year. Will you be ready to help them formulate a plan and offer the support they need to succeed?
This handout will focus on helping you work with your patients to develop a weight-loss plan, but the general principles could be applied to a variety of lifestyle changes.
The Process of Change
A smoker woke up one morning and decided to quit smoking. Some years later, he remains a nonsmoker. We’ve all heard this story, and we all know it’s the exception to the rule. Back in the day when smoking-cessation patches were prescription-only, the pharmaceutical companies knew it too—and in response, they formulated multifaceted smoking-cessation programs to support their customers, replete with toll-free customer support services and encouragement via mail campaigns.
The vast majority of dieters go it alone, much like our cold-turkey nonsmoker, but with drastically different results. They are plagued by their inability to lose weight and keep it off. For those who can be counseled that weight loss is a process that requires careful planning, patience, and commitment, the chance of success improves dramatically.
Your role in this process is multifaceted and may vary from patient to patient. You many need to help the patient:
- identify motivating reasons for losing weight;
- develop a plan and goals that span the weight-loss process;
- provide strategies and tools; and
- refer to allied health professionals (i.e, dietitian and exercise physiologist) when necessary.
The Change Cycle
According to Prochaska et al the first step in lifestyle change counseling is to determine where the patient is in the change cycle. Get the patient talking and listen. Has she not yet begun to think about (precontemplation) or is she just beginning to consider (contemplation) change? Maybe she has established a target date for starting (preparation) or has just started a new diet (action). Has she lost a significant amount of weight and is struggling to keep it off (maintenance), or has she had a setback and put on a few pounds (recycling)?
Your approach should be tailored to where the patient is in the change cycle. The patient in the preparation cycle may need help establishing tangible and realistic goals, whereas the patient in the action, maintenance, or recycling cycle may need specific strategies or tools to help her stick to the plan.
The National Heart, Lung, and Blood Institute (NHLBI) recommends the following steps to treat overweight and obesity:
- measure height and weight and estimate BMI (see Table);
- measure waist circumference;
- assess patient motivation;
- recommend a diet; generally, a diet containing 1,000-1,200 kcal/d should be selected for women; a diet containing 1,200-1,600 kcal/d should be chosen for men and may be appropriate for women who weigh 165 lbs or more or who exercise regularly;
- discuss physical activity and establish a physical activity goal; a wide variety of activities may satisfy this goal, including walking, dancing, and gardening;
- encourage the use of a weekly food and activity diary;
- provide dietary information; and
- note goals in the patient record and track progress on subsequent office visits.
Identifying Motivators and Potential Barriers
Throughout the process, but especially as part of the preparation cycle, it is imperative to identify both motivators and potential barriers to success.
Staying motivated and keeping a positive attitude are major challenges in any weight-loss program. By identifying potential barriers, the patient can anticipate, and possibly avoid, difficult situations that may hinder progress and erode a positive attitude. For example, an overweight mother may need to arrange for childcare or join a gym that offers childcare in order to pursue an exercise program.
Most weight-loss patients already have an idea of how much weight they would like to lose. In addition to ensuring that this goal is reasonable, you should help establish several goals that are not related to weight:
- a change in size—clothes fit differently;
- an improved medical condition—lipid levels have changed sufficiently to require reduced medication;
- increased exercise capacity—walking longer or farther than at program inception;
- increased fruit and vegetable consumption; and
- improved body mass index (BMI).
Having multiple goals will not only create a balanced focus, but also will build confidence throughout the program as these goals are met.
Just as importantly, patients should be encouraged to establish rewards for meeting significant milestones along the way.
When establishing these goals and rewards, keep in mind the patient’s reasons for wanting to lose weight and plan accordingly. For example, if one of the patient’s motivators is to be able to be more active with his children, a reward may involve a special outing with the family.
Tools and Strategies
The NHLBI’s Practical Guide (see Resources) provides a useful counseling tool for primary care physicians that includes patient resources on shopping, dining out, and food preparation.
As with any behavioral change, it is important to:
- emphasize the positive over the negative—a simple recommendation to eat five fruits and vegetables daily may lead to better overall dietary habits;
- celebrate successes and progression from one change cycle to another;
- emphasize patience and the process in the face of a setback; and
- listen to the patient.
Miller WR, Rollnick S. Motivational Interviewing. New York: The Guilford Press; 2002.
NHLBI Obesity Education Initiative. The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. Available at: www.nhlbi.nih.gov/guidelines/obesity/prctgd_c.pdf. Accessed Dec. 7, 2002.
Prochaska JO, et al. Changing for Good. New York; Avon Books; 1995.