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Conversations about Weight Management

3. Brief

This section covers:

  • Assessing readiness to change
  • Goal setting: how to set realistic Goals

The brief intervention involves using positive messaging that encourages increased consumption of vegetables and fruit, drinking more water and physically moving more.

Resources that can be utilised in the brief intervention are:

There should be no limits on coloured vegetables and fruit intake. Most people do not eat enough for good health. Encourage at least 5+ per day (3 vegetables, 2 fruit). Ideally increase to 9+ per day if appropriate (5-6 vegetables, 3-4 fruit). Preserved, canned, dried options are acceptable. Less is best with processed foods.

The aim is to increase the micronutrient content in the diet from more micronutrient-dense foods such as coloured vegetables, fruit and nuts and seeds.

For individuals who are currently sedentary and/or peripherally overweight, start low and go slow when increasing activity levels. Moving more will enhance a person’s mood.

If opportunity and time permits, consider assessing the following: (A+B forms)

  • Current intake of vegetables, fruits and nuts per week
  • Minutes of physical activity per week and huff and puff exercise
  • Height, weight and waist circumference – How to take body measurements

There is a general lack of patient weights, try and weigh your patients at least once a year.

  • Blood tests when patients seen in General Practice – this document explains what blood tests can be useful to order and why

Try helping the patient come up with a SMARTA goals based on the brief intervention messages (more information on setting SMARTA goals later).

Assessing readiness to change

In order for people to change they need to be willing, able and ready to make some changes to their lifestyle. These questions are important to ask as they determine whether you should progress to “ongoing management. People are more likely to attend appointments and make positive lifestyle changes if they score 6 and above.

Compared to previous attempts to change your eating, how motivated/willing are you to improve your eating at this time?

  • 1. Not at all
  • 2. Slightly
  • 3. Somewhat
  • 4. Very
  • 5. Extremely

Considering all outside factors at this time in your life (stress you are feeling at work, your family obligations, etc.?) how confident are you that you will stay committed to an improved eating pattern program?

  • 1. Not at all
  • 2. Slightly
  • 3. Somewhat
  • 4. Very
  • 5. Extremely

Add the scores together to get an overall score.

Scoring: Not ready to change

Scores 5 or less: The person is probably not up to changing currently and the ABO weight management programme may not be suitable for them at this time. This is OK – use non-judgemental attitudes, tones and content of communication. Use of motivational interviewing (information below) may harness the person’s intrinsic motivation. All clinicians and health care workers can help with:

  1. Reiterating the key messages about eating more vegetables and fruit, and being more physically active. Beware of shrinking a bad diet that will not improve well-being or health.
  2. Sorting out mental and physical problems that stop people being able to change e.g. problems at home or medical problems.
  3. Supporting the person and displaying empathy whilst people they are trying to get themselves into the ‘readiness head space’ – this is the person getting ready to manage their addiction. Provide an open invite for the person to make a further appointment when they feel /willing/able/ready to make changes.

You can still utilise the brief intervention resources and posters to support the key messages.

Motivational Interviewing when a person scores 5 or less:

Motivational Interviewing is a directive, client-centred counselling style for eliciting behaviour change by helping clients to explore and resolve ambivalence (unsureness). It has been used in people with eating control problems2. This style of consultation can assist with overcoming barriers in people who are not ready to change. Motivational Interviewing involves empathy, collaboration (partnership), evocation (listening and eliciting), and autonomy (ability to choose).

Is the person willing, able and ready for change?

  • Willing: The importance for people to makes changes, often one thing at a time, indicates their willingness to change. The clinician can help by filling in, updating and educating people on items/behaviours/environments that are supported by basic and evolutionary evidence, and ‘myth bust’, to prevent setting up people to fail. E.g. does the person have enough knowledge and support?
  • Able: A person’s confidence affects their ability to make changes. Helping people with psychological and/or physical problems e.g. depression and anxiety treatment, pain management for arthritis, managing sleep apnoea (see later), needs to come very early in the process. People must be enabled, thus helping with these issues can precede weight management and/or be undertaken at the same time. E.g. does the person feel confident they are ready to change (physically and mentally)?
  • Ready: A matter of priorities and getting support to manage control over eating is necessary to take the final steps into action. This last point about ‘readiness’ is the area that this programme acknowledges – we need to support people and sometimes wait as they get to the point to act. Offer to be available to follow up when they are ready. This is the same for all ‘addictions’. E.g. Are you ready now e.g. have you ‘emotionally and mentally’ got ‘yourself organised or sorted’ or into the ‘right headspace’, in other words can you address barriers e.g. cravings, addiction, yet?

A horizontal bar representing a simple numerical scale (a Likert-type18 scale) can be utilised to determine the level of importance and to harness the people’s intrinsic motivation to change by, for example, asking:

“On a scale from 1 to 10…” 1 being unimportant and 10 being very important “How important is it for you to…?”

Regardless of the number provided ask the person why they did not select a number at least 2 points lower, i.e. why did you say 5 and not 2. This is one of the rare times during motivational interviewing that you use the questions why? The usage of why nearly always provokes a defensive response and therefore should generally be avoided. However, in this case you desire a defensive response, you want the person to defend why they selected a higher number as they will automatically tell you all the positive reasons why they selected a higher number.

If you want the person to start action planning you can use Likert type scales in other ways, for example,

e.g.  “What would it take to get you from 3 to 6?”

This promotes problem solving and action planning. These are important steps as behavioural change is unlikely to be achieved in their absence. Access online learning to increase your knowledge and skills of motivational interviewing. One good online learning course is Motivational Interviewing in Brief Consultations. This is available via BMJ online, is free of charge and takes less than one hour to complete. The example used is for stopping smoking (where there is also an addiction component) but is adaptable to weight management. There is also an online animation called Change Talk (must use Firefox, Safari or Internet Explorer).

Scoring: Ready to change

Scores of 6 and above indicate the person’s willingness (importance) and/or confidence/readiness to change. Book an ‘ongoing management’ appointment for the first weight management assessment and intervention.

In the meantime encourage the person to eat more vegetables and fruit, and be more physically active. SMARTA goals should be agreed with the person based on the findings from asking about baseline vegetable, fruit and exercise.

The Comprehensive Assessment Tool will ideally be initiated during the first appointment for on-going management. This first assessment could take some time (around 45 minutes) if filled out with the person. It will highlight areas for potential change and guide your management.

For some people the assessment can be revealing and emotional as this may identify issues which have not been revealed previously. For the best outcome, utilise motivational interviewing skills to develop a SMARTA goal in partnership with the person.

Alternatively, patients can be given an online link to fill out the comprehensive form at home before the first ongoing management appointment, provide an email address so they results get sent back to you.

Comprehensive form: http://www.surveygizmo.eu/s3/90006875/weight-management-cat

Goal setting: how to set realistic Goals

SSpecific
MMeasureable
AAction-Orientated
RRealistic
TTimely
AAgreed (create the goal with the person you are seeing, not for them)


Brief interventions and ongoing management are best implemented with motivational interviewing and SMARTA Goals. These should initially be directed from the results of the Comprehensive Assessment.

SMARTA goals focus on realistic actions/steps that can be achieved. Final goals/outcomes such as a weight loss cannot be predicted and can set people up to fail, leaving them feeling guilty.

SMARTA Example: I will eat 3 handfuls of coloured vegetables with my main meal 5 nights a week.

SMARTA goals are real things that can be done. E.g. If someone was doing no exercise, agreeing on a specific, achievable goal such as going for a 10 minute walk twice a week is an improvement. This goal can/should be built upon over time with the aim of getting to recommended levels.

If opportunity and time permit, consider asking about & recording and/or encourage the person to record and return to clinician later, baseline markers in the brief intervention (A & B screening tools).

Record current:

  • Intake of vegetables/fruit/nuts per week
  • Minutes of physical activity per week (and higher intensity exercise)

The person can be asked to record what they did before, and when they come back report how much they have changed

  • Measuring height, weight, waist circumference (waist) and calculate the body mass index BMI (kg/m2) = weight kg/(height/m2) – How to take body measurements
  • Ordering blood tests when patient is seen in General Practice. Changes in nutrition and physical activity can reduce inflammatory markers as well as other metabolic biomarkers. – link to what bloods to order.