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Tuesday, October 9, 2007

Weight Wise Integration Tool

OK, the challenge is: can we create a simple tool that will allow busy primary care docs (and non-obesity specialists) to screen for and address obesity management issues in their patients?

The keywords in the last sentence are "simple" and "busy"! No point having a tool that takes 30 mins to work through - let's remember, the average PCP-patient encounter is presumably less than 10 mins.

So what would be a reasonable start? Well for one, it may be worth posing the question of whether or not this patient actually needs obesity management:

Is excess weight currently threatening or affecting this patient’s socioeconomic, mental and/or physical health?

1) Not threatening or affecting
2) Somewhat threatening or affecting
3) Quite threatening or affecting
4) Very much threatening or affecting
5) Definitely threatening or affecting

My guess is that if the answers are 1 or 2, then obesity management should be put on the backburner - monitor weight, counsel on avoiding weight gain, healthy eating, activity, etc. If the answers are 3-5, definitely need to consider addressing obesity management and move to the next question:

Does this patient present barriers to weight management?

1) Insurmountable barriers
2) Strong barriers
3) Moderate barriers
4) Minimal barriers
5) No barriers

I'd assume if the answers are 1 or 2 that this may not be the best time to begin thinking about weight management; if the answer is 3 one needs to see if the barrier can be overcome, if the answer is 4 or 5, well looks like there is no excuse to not start by asking the next question:

Is this patient ready to address excess weight?

1) Not thinking about change, resigned or in denial (Pre-contemplation)
2) Weighing benefits and costs of proposed change (Contemplation)
3) Experimenting with small changes (Preparation)
4) Taking definitive action to change (Action)
5) Maintaining new behavior over time (Maintenance)
6) Experiencing relapse (Relapse)

This one is pretty much based on the Prochaska and diClemente's Transtheoretical "Stages of Change Model" - I like the stage by stage intervention strategies suggested on the UCLA Nutrition site (and undoubtedly countless other sites):

Pre-contemplation:
- Validate lack of readiness
- Clarify: decision is theirs
- Encourage re-evaluation of current behavior
- Encourage self-exploration, not action
- Explain and personalize the risk

Contemplation:
- Validate lack of readiness
- Clarify: decision is theirs
- Encourage evaluation of pros and cons of behavior change
- Identify and promote new, positive outcome expectations

Preparation:
- Identify and assist in problem solving re: barriers
- Help patient identify social support
- Verify that patient has underlying skills for behavior change
- Encourage small initial steps

Action:
- Focus on restructuring cues and social support
- Bolster self-efficacy for dealing with barriers
- Combat feelings of loss and reiterate long-term benefits

Maintenance:
- Plan for follow-up support
- Reinforce internal rewards
- Discuss coping with relapse

Relapse:
- Evaluate trigger for relapse
- Reassess motivation and barriers
- Plan stronger coping strategies

All of this can probably be evaluated and addressed in a couple of mins - if not - it's unlikely to be practical for the busy family doc.

AMS

1 comment:

Yoni Freedhoff said...

Maybe with a comment we can get some comments rolling.

I like the concept of a PCP decision making tool, but wonder whether or not there's ever really a roll for putting weight management on the backburn in a patient whose weight confers medical risk.

I definitely think that there are a multitude of reasons for a patient to not undertake a weight management effort, and indeed some reasons why it may not be worth bringing up with the patient in the first place, but to put weight management on the backburner because it hasn't yet resulted in any medical comorbidities doesn't strike me as the best course of action and would be a failure of secondary prevention.

I think the first question can simply be, "Does this patient's weight put them at risk of medical, physical or socio-economic risk?" and if the answer's yes, move onto whether or not there are barriers in place that would in fact preclude recommending a weight management strategy (such as untreated clinical depression or a time of major life stress/upheaval).

Just my two cents.

Regards,
Yoni