The 5 A’s Approach To Obesity Counseling

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