Arya M. Sharma, MD

Behaviourial scientists have long suggested a framework for behavioural counselling known as the 5 A’s (ask, advise, assess, assist, and arrange).

This paradigm has been used to improve patient outcomes in smoking cessation, as in the TracII approach to smoking cessation here in Alberta.

As discussed in the recent Scientific Statement on New and Emerging Weight Management Strategies for Busy Ambulatory Settings From the American Heart Association, endorsed by the Society of Behavioral Medicine, published in the latest issue of Circulation,

“An adaptation of the 5 A’s for obese patients includes assessment of patient health risk, assessment of current behavior and readiness to change, advising the patient to change specific behaviors, agreeing about the behaviors and collaboratively setting goals, assisting patients in addressing barriers and securing support, and arranging for follow-up.”

For a start, a recently published randomized controlled trial (RCT) shows that training internal medicine residents in utilizing the 5 A’s obesity counselling strategy with obese patients, at least results in the majority of obese patients acknowledging that they had been counseled.

However, further evaluation of the counseling provided, revealed that

“residents in the intervention group did not address most of the 5 A’s. Furthermore, there were no actually significant differences in obesity counseling rates between residents in the intervention and control groups. This result may indicate the impracticality of the 5 A’s when implemented in a manner that relies entirely on physicians without infrastructure supports or help from other professionals.”

As the Statement correctly points out:

“Counseling about obesity is likely more complex and time-consuming than smoking cessation counseling. Even among studies that demonstrate the effectiveness of the 5 A’s paradigm for smoking cessation counseling by primary care physicians, physicians were more likely to complete the “ask” and “advise” steps and less likely to complete the remaining steps.”

The paper also describes the results of studies showing that strategies to increase the likelihood of patients themselves identifying weight as a problem or that provide clinicians with a way to “medicalize” the patient’s weight are most likely to increase the frequency of weight loss counseling in primary care visits.

Ultimately, although the ‘Ask’ question may be simple enough (would you like to talk about your weight?, are you concerned about your weight?) the Advise, Assess, Assist, and Arrange part of this approach are less clear - in fact, I would personally, probably complete the ‘assess’ step before venturing andy ‘advice’.

To be effective, the 5A’s obviously would require health professionals having at least a fair understanding of the causes and treatment of obesity and not fall into unhelpful ‘Eat-Less-Move-More’ platitudes.

To me, the ‘assess’ part of the 5A’s has to include what I have previously described as the 4 M’s, which will ultimately guide the Advise, Assist and Arrange part of the intervention.

Again, it is helpful to point out that while smoking cessation is a behaviour, losing weight is not. Thus, while the 5A’s may well be used to target behaviour change (e.g. eat breakfast, get enough sleep, do not eat in front of TV, etc.), whether changing these behaviours results in weight-loss or not, is a very different question.

Fortunately, successful obesity management (reducing obesity related health risk) and weight loss (dropping numbers on a scale) are not the same.

AMS
Edmonton, Alberta

p.s. other publications have described the 5A approach to include Ask, Assess, Advise, Agree, Assist and Arrange - a sequence that I personally find more logical and useful (especially the ‘Agree’ step).

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

One of the reasons that many health professionals do not bring up the issue or weight, is simply because they feel uncomfortable doing it.

So what is the best strategy and what does the research on this issue actually show?

This topic is a significant part of a new Scientific Statement From the American Heart Association, endorsed by the Society of Behavioral Medicine, published in the latest issue of Circulation.

Based on a systematic search of the literature on this topic (published between 2002 and 201), it is clear that patients describe a need for empathy, nonjudgmental interactions, and specific personalized recommendations.

As regular readers will recall, this is actually rule 1 of my 10 tips for family docs, and if nothing else, this is the only rule that all health professionals should adhere to - always!

While some patients associate even the word “obese” with discrimination, patients rate “‘weight” as the most desirable term, and “fatness” as the most undesirable term.

In my practice, I often also use the terms ‘large’, ’size’, or ‘big’ and have never had a negative response - much of how you use the language is determined by the general ‘non-judgemental’ manner in which the words are used. When I do use the term ‘obese’, I generally explain that I am using this ‘clinically’ as the ‘medical’ definition.

“Patients also express a preference for clinicians taking time to deliver weight loss counseling, rather than offering weight loss advice as an afterthought as they leave the room.”

“The importance of verbally recognizing patients’ small weight losses as well as their unsuccessful weight management efforts was also noted, because nonrecognition by providers was seen as a judgment that the patient did not care or was not making an effort toward weight loss.”

I generally do acknowledge changes in weight, but do not make them the topic of discussion unless I am specifically asked. Any comment would always be objective, non-judgemental and generally encouraging, no matter what - even a small weight gain could be worse!

When the patient brings up and insists on discussing the weight - this is always a good opportunity to explain (once again) that obesity management is not about weight loss and what is really important are the behaviours (weight loss is NOT a behaviour).

“Patients expressed an interest in hearing about how their weight was affecting their specific medical conditions (or risk for conditions) and an interest in receiving specific recommendations from the individual provider on how to lose weight rather than just broad statements about the need to lose weight.”

“Finally, physician recommendations related to diet and physical activity were more effective (ie, associated with greater likelihood of patient behavior change) if patients were given the chance to reflect on causes of their overweight during counseling visits and their own perceptions about weight management were incorporated into the recommendations.”

Yup, it never hurts to ask and listen to your patient.

“Beginning a conversation about weight is challenging and may be especially difficult if there are no readily available and affordable resources for patients genuinely interested in losing weight.”

This is definitely a problem, as most resources are either generically useless (focussing almost exclusively on “eat-less-move-more” platitudes) or consist of BMI charts and other material that is hardly useful. Of course, the fact that the ‘weight-loss’ industry is in the business of selling ‘weight-loss’ and is not in the business of providing obesity treatments, is a fine point that many patients (and professionals) find difficult to understand.

Overall, this is certainly an issue that will continue to prove challenging simply because most health professionals do have significant weight bias, tend to stereotype their obese patients, and too often have little more than a lay man’s knowledge of obesity themselves.

I am sure that readers will readily recall instances where communication on this topic could have been better.

AMS
London, UK

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

As not everyone may have a chance during the week to read every post, here’s a roundup of last week’s posts:

• Should We Outsource Obesity Treatments To Weight Watchers?
• Alberta’s Obesity Initiative: Not Just Diet and Exercise
• Is There Any Path For Approval of Anti-Obesity Drugs?
• GLP-1 Receptor Agonists, Obesity and Psoriasis
• Bariatric Surgery For Osteoarthritis of Hips and Knees?

Have a great Sunday! (or what’s left of it)

AMS
London, UK

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Yesterday, I posted on Alberta’s plan to tackle obesity by beefing up prevention and treatment efforts across the province.

Today, I discuss a paper by Susan Jebb and colleagues, just published online in The Lancet, comparing weight loss in people randomised to either ’standard’ care with their physicians or to Weight Watchers.

An accompanying editorial, suggest that doctors (or health systems) should perhaps give up on obesity treatments, as commercial programs (e.g Weight Watchers, Jenny Craig, etc.) do a much better job of this and may cost less.

In this parallel group, non-blinded, randomised controlled trial, 772 overweight and obese adults were recruited by primary care practices in Australia, Germany, and the UK. Participants were randomly assigned with a computer-generated simple randomisation sequence to receive either 12 months of standard care as defined by national treatment guidelines (n=377), or 12 months of free membership to Weight Watchers (n=395).

While only 61% of Weight Watchers participants completed the 12-month assessment, even fewer (54%) of standard care participants showed up for their 12-month assessment.

Perhaps, not surprisingly, participants in the commercial programme group lost twice as much weight as did those in the standard care group (−5·06 kg vs. −2·25 kg) at 12 months.

Based on these findings, the authors enthusiastically conclude that:

“Referral by a primary health-care professional to a commercial weight loss programme that provides regular weighing, advice about diet and physical activity, motivation, and group support can offer a clinically useful early intervention for weight management in overweight and obese people that can be delivered at large scale.”

Sure, but the question here is, for whom (or, in other words, for which patients) and, perhaps more importantly, with what benefit?

So who took part in this study: it would probably be fair to describe the participants as essentially healthy, slightly overweight, pre-menopausal women - in fact, the usual people, who show up at most commercial weight loss programs.

To be exact, the participants were 85% female, in their mid-forties, mildly obese at best (BMI ~31), and had perfectly normal blood pressures (124/78 mmHg), the occasional diabetes (6%) and a metabolic profile that would hardly raise an eyebrow from most health professionals.

While weight loss appeared to move some of these variables in a ‘positive’ direction, one would be hard pressed to find the odd parameter that barely reached ’statistical’ significance (let alone ‘clinical’ significance) - most clinicians would probably consider these changes little more than ’rounding errors’.

So what the study really shows is that if you randomise a group of otherwise healthy low-risk marginally overweight/obese women to a (albeit, admittedly great) commercial weight loss program, they do better at losing weight than when told to do so by their doctors (or other health professional) - and I’ll certainly believe that.

While I can see why the sponsor (Weight Watchers) and the authors (for publishing in The Lancet) may be celebrating, I see nothing in this study that would make me more enthusiastic about ‘outsourcing’ obesity treatments to a commercial Weight-Loss program).

And here are my reasons:

1) The people, who typically seek out commercial weight loss programs (like the participants in this study) are not who the obesity epidemic is really about. As we recently demonstrated in our large Edmonton Obesity Staging System (EOSS) papers, ‘healthy’ overweight and obese people (male or female) have very little if any health risk from their extra weight and should probably be left alone (certainly not be encouraged to lose weight). No one has yet demonstrated any long-term benefit of weight loss in this ‘healthy’ (Stage 0) obese population and there is far more potential to do harm than good (especially, when the weight comes back, as it most likely will - often with a vengeance).

2) While there is no doubt that Weight Watchers probably offers one of the most evidence-based and effective weight management programs (and is to be highly commended for investing in this study), it is hardly a model for everyone. Very few people have time for weekly meetings and weigh ins and high drop-out rates are the rule rather than the exception - for those, who can do it and enjoy such meetings, great - for most people, this is simply not a realistic option.

3) For all of its competence, expertise, knowledge and investment into offering a high-quality program, the delivery is by trained (and certainly very enthusiastic) lay people - this is why this model works great for ‘healthy’ obese folks. The minute we begin looking at obese people with real health problems, who need lab work, adjustments to their medications, close monitoring of their exercise and nutritional status, the notion that a trained ‘lay person’ alone can be of help is naive at best. Thus, you would in the end be paying double - money to Weight Watchers for weight loss, and still have to see your physician or nurse for managing your comorbidity (albeit perhaps not quite as often as weekly). In fact both Weight Watchers and the authors are careful in pointing out that the study only shows that Weight Watchers in conjunction with a primary care practitioner may be the way to go.

4) Although, much effort has gone into developing the Weight Watchers program and they certainly touch on many of the important aspects of healthy eating, activity, sleep, emotional eating, etc., in the end there is no formal etiological assessment or consideration of the actual causes of excess weight in a given patient. Obviously, I would neither expect a ‘lay program’ to appropriately diagnose depression, anxiety disorders, ADHD, binge eating, chronic pain syndromes, PCOS, obesogenic medications, or any of the other 200 causes of obesity that I can think of. In the end commercial weight loss programs sell weight loss and not obesity treatment.

5) Rather than interpreting this study as showing how great the Weight Watchers program is (and it is without question by far one of the best commercial programs out there), this study actually shows how miserable ’standard’ care for obesity is - or not? Perhaps the health professionals were indeed smart enough to recognise that very few (if any) of the participants in this study had anything to gain in terms of improving their health from losing weight, and so put little effort into actually doing anything about it. Certainly, in my practice, I would not be wasting my nurses’, dietitians’, psychologists’, or anyone else’s time by referring the majority of these ‘participants’ to any weight loss interventions in our clinic.

The messages for me from this study are loud and clear:

1) ‘Standard’ care is clearly below standard (assuming that we’d see the same result if the participants actually did have a medical reason to lose weight).

2) We need to tell more people that losing weight when you are otherwise healthy may not actually be of any real benefit (of course, we could argue that if Weight Watchers just helped people eat healthier and be more active without any weight loss, they’d probably have the same impact on participants’ health (or not) - but then, who’d pay for that?)

The idea that, based on this study, anyone would even playfully (let alone seriously) suggest that obesity treatment should perhaps be best left to commercial weight loss programs, is not only ludicrous but reflects a rather simplistic view of what I (and many others) would consider a pretty complex and often complicated chronic disorder.

This is not to say that there is no role for Weight Watchers in helping people better manage their weight (and health?).

Weight Watchers, through its network of group meetings and online resources, certainly has the ability to reach far more people than doctors or nurses sitting in their offices.

I would also not be surprised if Weight Watchers has perhaps done more to educate people on healthy eating than anyone else.

Certainly, they have invested more in backing their program with hard evidence than any other commercial weight loss program.

But if Weight Watchers really wants to put their money where their mouth is, and help people not just lose weight but actually get healthier, I’d now like to see a similar study in EOSS Stage 2/3 patients.

I guess, they know where to reach me

AMS
Edmonton, Alberta

One of the basic tenants of behaviour change is goal setting. A popular framework for this is S.M.A.R.T., which stands for Specific, Measureable, Attainable, Realistic and Timely.

But does goal setting in behaviour change actually work?

This question was addressed by CON-Bootcamper Erin Pearson from the University of Western Ontario (London, ON), in a paper just published in Patient Education and Counselling, in which she reports her findings from a systematic review of the literature.

Specifically, this paper describes goal setting components used for behavior change specific to diet and physical activity in community-based interventions targeting overweight and obese adults.

Eighteen studies were evaluated using the S.T.A.R.T. (Specificity, Timing, Acquisition, Rewards and feedback, and Tools) criteria which were developed for the purposes of this paper in order to elucidate which intervention features elicit optimal health behavior outcomes.

The analyses, however, ran into problems as, despite suggestions that developing specific goals that are in close proximity, involve the participant in acquisition, and incorporate regular feedback, are common features in these program, it was not possible to ascertain whether this goal setting element in itself was useful or not, as it was generally confounded by other intervention components such as education sessions or self-monitoring records.

Thus, Pearson concluded that while goal setting shows promise as a tool that can be incorporated into weight reduction programs by health care professionals and researchers, further studies are warranted to identify the specific mechanisms through which individuals with overweight or obesity can apply the S.T.A.R.T. criteria with respect to goal setting for the purposes of weight loss.

One aspect that is clear to me at least is that weight-loss itself should not be a goal as weight loss is not a behaviour. If the goal of the intervention is to change behaviour then the goals should probably be behavioural goals that meet the S.M.A.R.T. (or S.T.A.R.T.) criteria.

Whether or not these behaviour changes actually result in sustainable weight loss is likely irrelevant as long as they improve health.

Thus the goal to eat a proper breakfast on at least five mornings a week or to not eat out more than two times a week or to walk at least 5,000 steps on four days a week are specific, measurable, attainable, realistic and timely behavioural goals, whereas losing 10 lbs by the end of the month is not - why? Because “weight loss” is NOT a behaviour!

Indeed, I have warned before that there is an inherent danger of aiming for weight-loss goals:

1) patients tend to focus more on the numbers on the scale than on the actual health behaviours

2) if the weight goal is not achieved patients are generally disappointed, disheartened and likely to abandon the program altogether (along with the healthy behaviours)

3) Even if patients do achieve their first weight-goal, they tend to set new (even lower) weight-goals, which lead to the same problems described in 1 and 2 - ultimately they end up setting a weight goal that is either unachievable or unsustainable and the chances are that the lower the goal, the unhealthier the strategies used to achieve and/or sustain it.

Thus, while I fully support the notion of SMART (or START), the goal should be a behavioural goal and not weight loss.

Just remember that weight-loss is NOT a behaviour.

AMS
Edmonton, Alberta

Pearson ES (2011). Goal setting as a health behavior change strategy in overweight and obese adults: A systematic literature review examining intervention components. Patient education and counseling PMID: 21852063