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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).

AMS
Edmonton, AB

7 Comments

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

    When I first read all the “myths” I had a hard time understanding how #4 was a myth! Partly because in my own experience I was not successful in losing weight until I was truly ready to take – and sustain – the action required to do it. So, for me, #4 was not a myth, it was a truth. Your statement above explains it well.

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  2. This is purely anecdotal of course but in my work as a consultant to very overweight people (seeking to lose 100lbs or more) I always notice a difference between those who appear to present a “whatever it’s going to take” attitude vs. those who want to talk a lot about what they will be “allowed” to eat, can they have “cheat days,” what treats are alright, and just a general on-going pre-occupation with food. They also have a persistent belief that if they don’t “treat” themselves, they will be driven to binging. I think they’ve heard that in the media and they turn it into a self-fulfilling prophecy.

    I also always talk to people about “why” they believe they are overweight. I see a big difference between people who have more of a behavioral insight into their own habits vs. people who believe they have been suffering the consequences of some kind of trauma they point to as a “cause.”

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  3. The reason people do not maintain losses with behavior is that over and over, in multiple media — from women’s magazines to “doctor supervised” weight loss centers — people hear the message that maintenance is a time when you can “add back” food items that you restricted during the loss stage and find a more comfortable exercise level. People need to be told the truth, that the level of food restriction and the intensity of exercise that you will have to maintain for the rest of your life, no vacations, will be comparable (or progressively more intense) than the level you are at the week you lose your final pound. If they understood the truth, then their contemplation would be more productive. They would likely give up weight goal setting for behavior goal setting. “What behaviors can I maintain for the rest of my life?” Then they would just see what came about weight-wise, as well as results in their lipid profile and other health measures.

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  4. @DebraSY – I agree with you that weight loss maintenance relies on the dieter maintaining the same level of food restriction and exercise that got them to their goal weight, and that this is usually glossed over in the popular media.

    However, I think you are being overly negative in asking the would-be dieter what kind of behaviour they can maintain for the rest of their life. It’s like asking someone if they will enjoy the view from the top of the mountain before they have even laced up their hiking boots. If someone had told the morbidly obese me what my lifestyle would have been like in 2013, I would have run screaming in horror.

    Many people, like me, grew up believing that they “hated exercise”, only to find that they actually enjoy it, once they have the opportunity to work out without the high school gym coach screaming at them. Similarly, many people believe that they hate healthy food/couldn’t live on X diet without ever having tried it.

    In other words, no-one can know until they get there.

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  5. Personally, all of my big lifestyle changes started with a small maybe. Maybe trying a new way could work. I wasn’t convinced, but I wasn’t completely close-minded about change either. And I certainly wasn’t having willpower or being highly motivated either. Just a small maybe.

    🙂 Marion

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  6. All I have to say is “I love your lottery ticket analogy”. Definitely one of the clearest and most charming analogies ever. The epidemiology folks will like it. I think the stages of change are good for the family docs as they can help the patients get to the next level, it is part of the 5As. It is an ongoing discussion. Once the patient is referred to the weight management clinic, the stages of change are over.

    What we need is “Wharton’s – Stages of Understanding”. 1. Main ideas of weight gain and weight loss are commercial based, non-scientific 2. Gained greater understanding about genetic and environmental aspects of weight gain 3. Understands the chronic nature of obesity and the cycles of weight management 4. Prepared to tackle obesity with realistic goals of success and failure. 5. Committed to improving overall health over the long term.

    I am sure this needs refining, but it’s a start. 🙂 Cheers Sean

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  7. ‘Readiness’ was a big part of my recent success with the HCG Protocol (I’m on my second 6 weeks), which in my mind, right or wrong, is a cure for my obesity as recommended by my GP and NP. Maintenance definitely worries me because I still have the eating impulses, emotional eating and psychological patterns to deal with. Dealing with these HAVE to be part of the ‘cure’ as far as I am concerned, otherwise I have no hope of keeping the weight off. In the mean time I read this blog, which I really like, continue with co-counselling, peruse articles and books that speak to my predicament and carry on doing the best I can with the tools and emotional and mental skills I’ve developed. Its not a simplistic A, then B, then C for everyone, but I like the idea of working through the stages that could be designed for the individual, not necessarily the masses. As far as whether or not readiness could be a predictor of success, I don’t know how one would measure the amount of readiness to test this theory.

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