Tuesday, September 20, 2011

Readiness To Do The Right Thing?

One of the most pervasive behavioural modification paradigms is Prochaska and DiClemente’s stages of change: precontemplation, contemplation, preparation, action, and maintenance.

It is therefore not surprising, that the recent Scientific Statement on New and Emerging Weight Management Strategies for Busy Ambulatory Settings From the American Heart Association, recommends the use of this paradigm in obesity management.

As the Statement points out:

“…providers should ask whether they want to lose weight and whether they believe they are ready to make changes to promote weight loss.”

The statement describes the use of a simple 5-item questionnaire, used in a descriptive study in a primary care setting, in which patients were asked to choose which of 5 statements best described their readiness for weight loss:

“I have not really thought about it” (pre-contemplation)

“I mean to lose weight but I don’t actually get around to it” (contemplation)

“From time to time, I go on a diet/exercise, but then I stop after a few days” (preparation)

“I have been working on losing weight for the past 6 months” (action)

“I have been working on losing weight for over 6 months, or I have kept my weight I lost off for over 6 months” (maintenance)

According to this study,

“Patients who were in the latter 4 stages of readiness were more likely to recall having received counseling for weight loss than those in the precontemplation stage.”

Based on this and similar studies, the Statement goes on to suggest

“…that although assessing readiness to change adds an extra step in caring for overweight and obese adults, it is a useful indicator of whether any accompanying weight loss counseling will be recalled by the patient. A patient who at least recalls weight loss counseling is better equipped to take steps toward weight loss than one who does not.”

While there is certainly nothing wrong with the ‘Readiness for Change’ paradigm in that someone in the ‘pre-contemplation’ or ‘contemplation’ stage may not be ready to embark on weight management, I often encounter patients, who are more than ready and are already ‘preparing’ or even ‘acting’, but just not preparing for or doing the right thing.

So for e.g., it is not uncommon at all, to meet patients ready to ‘lose weight’ and anxious to follow a diet or exercise plan but completely unready to actually deal with the underlying psychological or other issues that would really need to be tackled for any chance at keeping the weight off.

We see patients ready to exercise but not ready to give up their daily supply of pop, patients ready to eat more fruit and vegetables but not ready to have breakfast, patients ready to join a commercial weight loss program but not ready to tackle their abusive marriage, patients ready to go on a low-calorie diet but not ready to consider treatment for their depression.

These are patients, who are ‘ready’ to do the wrong thing but far from ready to do what is really necessary.

So being ‘ready’ alone is hardly a measure or predictor of ‘success’.

I am also not comfortable with how the ‘Readiness for Change’ model is presented in this Statement, as the focus is clearly on weight-loss, which, I cannot emphasize enough, IS NOT A BEHAVIOUR!

To be useful as a behavioural change model, the focus should be on changing a behaviour (keeping a food diary, turning off my lights at 10 pm, adding 20 mins of relaxation exercises to my daily routine, etc.).

A key challenge for health professionals, thus, is not just helping clients across the Stages of Change, but also, ensuring that their readiness is indeed focussed on doing the right thing – this, of course, is easier said than done.

AMS
Edmonton, Alberta

Rao G, Burke LE, Spring BJ, Ewing LJ, Turk M, Lichtenstein AH, Cornier MA, Spence JD, Coons M, & on behalf of the American Heart Association Obesity Committee of the Council on Nutrition, Physical Activity and Metabolism, Council on Clinical Cardiology, Council on Cardiovascular Nursing, Council on the Kidney in Cardiovascular Disease, and Stroke Cou (2011). New and Emerging Weight Management Strategies for Busy Ambulatory Settings: A Scientific Statement From the American Heart Association * Endorsed by the Society of Behavioral Medicine. Circulation, 124 (10), 1182-1203 PMID: 21824925

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7 Responses to “Readiness To Do The Right Thing?”

  1. AcceptanceWoman says:

    I have to say that I love your emphasis on weight loss not being a behavior. I feel like I’ve been screaming this from the rooftops and it makes me insane when I read something that calls obesity a behavior.

    As far as stages of change go… I did test out an online weight loss intervention that was developed with Prochaska that couched the readiness for weight loss in terms of readiness to accept “facts” — one of those was that if one is overweight or obese, one must either be eating “too many” calories or regularly consuming unhealthy foods. I felt uncomfortable “copping to” either of those. I did have an impact on how I thought of myself, in a somewhat unpleasant way (I think that for people like me with a fairly external locus of control, there can be harm in “breaking” precontemplation).
    If I am interested in weighing less, it’s true that I will need to change the composition of my diet in order to do that, but what if I am truly not interested in weighing less? What if I decide that for me, staying at a stable weight is better?
    I think it’s all about how the provider asks the question. I think focusing on behaviors is probably a better way to go.
    I think that ideally, if a person is focused on engaging in healthy behaviors, and there is a weight gain that the person wants to address, that conversation could initiate with the patient in the interaction.

  2. catherine says:

    Your blog post today reminds me of a book called Thin for Life by Anne Fletcher. She has a great chapter in this book that has a checklist on preparing yourself for the journey into weight loss. I think it is a great book with lots of stories of how people got to where they did and were able to stay there. The author even discusses the name of the book and how she arrived at the title. Definitely worth reading for some. The emphasis on weight loss as not a behavior is such a great point.

  3. Casey says:

    I think there should be another stage added.”I have been working on losing weight for the last 6 months+NO WEIGHT HAS BEEN LOST!(gained a few pounds)I am one of those people who journals,counts calories,exercises,weighs+measures my food.Also been a T.O.P.S. member for the last 6 months.Why is there no mention of people like me who are doing everything in their power,including asking their Doc for help+NOTHING happens.

    What else can I do?(other than wait 2yrs to get into the obesity clinic)Please,any suggestions would be greatly appreciated.+No I have not been cheating or mistaken on what I’ve been doing because my husband has been doing this with me+lost 25lbs.

  4. DeeLeigh says:

    Based on the title and the first part of this post, I was ready to head-desk. First, the “right thing to do” is not always to attempt weight loss. In fact, i believe that weight loss and weight loss attempts are completely without moral or ethical meaning; they are not “right” or “wrong.”

    Second, if I was asked to choose which of 5 statements in the post best described my readiness for weight loss, I’d have to say that none of them applied to me at all. Where’s “I have thought about it a lot and decided that weight loss is not going to be a goal for me?” The whole structure is designed to shoe-horn people into a particular pattern and course of action. Maybe that’s the intent, but it won’t work for (on?) a lot of people.

    I was relieved to see you acknowledge that some patients are ready to join a commercial weight loss program but not ready to tackle their abusive marriage… ready to go on a low-calorie diet but not ready to consider treatment for their depression.

    The most advantageous life changes and the most important health issues to concentrate on sometimes have nothing to do with weight at all. That is so true and so important to emphasize.

  5. Lucy A. says:

    Change happens slowly like physical growth, there needs to be the right ingredients to produce change. In a few cases the change is education as to what good calories are made up of versus empty ones.

    I needed to know where the best starting point is–that was my case–most of the Weight Wise information was not new, however it needed to be rearranged so that I could put it to best use.

    The food journaling did especially helped. It is imposible to cut back on calories consumed until you know how many you are consuming; let alone figure out what works for you.

    Just as different people mature at a different rate it is very posible that different people get to the point of this weight is is enogh at a different point in life and are not ready to deal with the personal issues that may be encouraging them to overeat. Sometimes the diet isn’t the first thing that should be delt with and for these the tread mill of obisity lingers.

    Thank you for this artical on stages of change

  6. Frontier Psychiatrist says:

    Not convinced with the model, and the ‘process’ worked through to move through them, especially for such multifactorial conditions as obesity.

    http://www.nature.com/oby/journal/v17/n4/pdf/oby2008609a.pdf

    link looks at measurement of stage of change and outcome of bariatric surgery

  7. hCGBoost says:

    This page is a really trustworthy article. Lossing weight is benificial for your well-being and happiness.

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