Obesity Myth #4: Readiness For Change

Myth #4 addressed in the recent New England Journal of Medicine article on obesity myths, presumptions and facts is:

“Assessing the stage of change or diet readiness is important in helping patients who seek weight-loss treatment.”

This myth alludes to the use of Prochaska’s transtheoretical model of Readiness for Change, which identifies various stages beginning from precontemplation, to contemplation, to preparation, to action, to maintenance (some authors also include a stage of relapse)

With regard to this “myth”, the authors note that

Readiness does not predict the magnitude of weight loss or treatment adherence among persons who sign up for behavioral programs or who undergo obesity surgery.”

In support of this being a “myth”, the authors quote five trials (involving 3910 participants; median study period, 9 months) that specifically evaluated stages of change (not exclusively readiness) and showed an average weight loss of less than 1 kg and no conclusive evidence of sustained weight loss.

As a possible explanation for this finding the authors offer:

“…people voluntarily choosing to enter weight-loss programs are, by definition, at least minimally
ready to engage in the behaviors required to lose weight.”

I would take a somewhat different view of this based on my own experience with assessing readiness for change.

There is no doubt that someone, who is not ready, is unlikely to be successful at losing weight and keeping it off. It certainly takes more than a “pre-contemplator” or “contemplator” or even someone, who is in “preparation” to actually begin doing something that will affect their weight – thus, by definition, anyone, actively trying to lose weight is already in the “action” phase. (I have never met a pre-contemplator who agreed to undergo bariatric surgery).

The real question is therefore whether or not being in the “action” phase will predict outcomes. Here, of course the answer is no.

Just because you are actively doing something to manage your weight (action stage) does not mean that you will be successful – after all, the vast majority of people, who try to lose weight, ultimately fail to keep it off.

Thus, it is easy to see why there is little relationship between Stages of Change and outcomes, when one considers all comers.

This, however, in clinical practice is not really the point of assessing readiness.

Rather, the clinical utility of this framework is to assess whether or not someone is even close to embarking on any kind of weight management and moving them along this continuum if they are not.

While being in the action stage does not guarantee success, being a pre-contemplator, contemplator, or even preparer, virtually rules it out.

Were you to liken success in losing weight to winning a lottery, the person in the action phase at least bought a ticket (the others are still only thinking about buying one). I know of no lottery that you can win if your don’t buy a ticket.

Yet, if I were to study the chances of winning a lottery, it may well be hard to prove that buying a ticket actually increases your chances of a win. (Imagine a lottery where the chances of winning are one in a million and we compare the odds of winning amongst two million people randomised to either buying a ticket or not. We will end up with one winner in the ticket group and no winner in the no-ticket group – not enough to statistically prove that buying a ticket increases your chances of a win. Yet, we would all agree that not buying a ticket virtual guarantees not winning – statistics or no statistics!)

Although, the odds of losing weight and keeping it off may be far better than of winning a lottery, it is still a rather rare event.

Thus, while I agree with the authors that simply being ready may only marginally (if at all) increase your chances of success, I can assure you that not even thinking about it virtually guarantees failure.

This is why, I believe that a conversation about readiness is a sensible conversation to have with anyone wondering about their weight (by definition, this would already be a contemplator).

Edmonton, AB