We Need to Change

If you have ever quit smoking or lost a lot of weight, then you know how hard it is to change your life. You wouldn’t be alone in feeling that your doctors didn’t care about your struggle… or perhaps even judged you.

The healthcare industry is clearly having a difficult time with overweight and obesity in America. It’s estimated that more than half of today’s children will be obese by age 35.

What can we do about this?

Starting the Conversation

Physios have the time, resources, and knowledge to be leaders in promoting weight loss. When I started practicing, I was afraid to even discuss nutrition or patients’ weight. Patients would often mention their desire to lose weight or, alternatively, their skepticism that their weight has anything to do with their pain. I was never the first person to bring up the topic.

But not anymore. 

I work with many patients who want to lose weight in order to manage their osteoarthritis. One of my favorite questions toward the end of my subjective interviews with patients is this: “Are there any other goals that you have that we haven’t talked about?” 

This is usually where our meaningful conversations about weight loss happen. But sometimes I felt uncomfortable with knowing what I should say or how I could steer the conversation without offending yet still offer something valuable to patients.

The 5 (or so) A’s

The 5 A’s method is based on the transtheoretical model of behavior change. This method helps to provide some guidance on how we can approach these conversations.

The 5 A’s model has evolved, initially designed for smoking cessation but recently adapted for obesity management. The 5 A’s as they relate with weight loss are ask, assess, advise, agree, assist, and arrange. (I know, that’s actually 6 things. More on that in a minute.)

Definition: Asking the patient about habits, behavior patterns, weight, nutrition, and readiness for change.

  • “How do you feel about your diet?”
  • “How do you feel about your exercise routine?”
  • “What goals do you have related to your health?”

Definition: Assessing the patient’s BMI, waist circumference, quality of diet, physical activity status, psychosocial factors, environmental milieu.

  • “What challenges have you faced with trying to lose weight?”
  • “How does your family feel about your goal to lose weight?”
  • “It sounds like we can try to increase your physical activity.”

Definition: Giving clear, specific, and personalized behavior change information, which includes health risks and benefits.

  • “If you were to lose 5-10% of your body weight, then the odds are that you would feel less pain in your knees.”
  • “Losing weight is a fantastic way to lower your blood sugar and blood pressure, which could help you to live longer and to feel better.”

Definition: Collaboratively selecting appropriate treatment goals and methods based on the patient’s interest and willingness to change.

  • “It sounds one goal could be to lose 20 pounds over 6 months, which would be 1 pound per week. How do you feel about that plan?”

Definition: Aiding the patient in achieving goals that were established together, by teaching skills, providing confidence, and supplementing with other medical treatments when necessary (e.g., pharmacotherapy).

  • “What barriers do you foresee with your goal to eat fewer carbohydrates?”
  • “What are some things to tell yourself when you don’t feel like exercising?”
  • “What are some ways that you can feel more supported by your family in this journey?”

Definition: Scheduling follow-up contacts, adjusting the treatment plan as needed, and providing referrals for specialists when appropriate.

  • “I’m going to give you a phone call in two weeks to see how your plan is going, and please let me know if you have any issues along the way.”
  • “Because you’d like some specific meal plans, I’m going to refer you to a registered dietician for assistance.”

Our Map to Change

The 5 A’s model has been adapted by different organizations, with some choosing to use “agree” and others choosing “ask,” and so on, but I think all are important.

Here’s the problem: This list might trick you into thinking this process is linear. I don’t think it is. Sturgiss and van Weel provide a beautiful image for how we can use this strategy while taking a patient-centered approach, assuming a strong therapeutic alliance.

This image below from their paper provides a lot to consider. What if a patient isn’t ready to discuss weight loss? What if they know what to do but want more assistance? The authors provide us with a roadmap for the ongoing mission of achieving a healthier world.

What’s Next?

If you liked this post, then I would love to hear from you! Leave a comment or tweet me @zachrstearns — just use the hashtag #physioweekly.

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