A 54-year-old woman comes to the office for a yearly preventive examination. She has no specific concerns. Blood pressure is 144/95 mm Hg and pulse is 86/min. BMI is 50 kg/m2. Examination shows severe obesity but is otherwise unremarkable. Fasting glucose is 128 mg/dL. When the subject of her weight is mentioned, the patient says, "In my family, we just like to eat. My mother is heavy, my father is heavy, and my kids are heavy. There's no point in trying to lose weight now." Which of the following is the most appropriate response to this patient's statement?
Stages of change model | ||
Stage | Motivational interviewing | |
Precontemplation | Not ready to change: patient does not acknowledge negative consequences |
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Contemplation | Thinking of changing: patient acknowledges consequences but is ambivalent |
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Preparation | Ready to change: patient decides to change |
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Action | Making change: patient makes specific, overt changes |
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Maintenance | Changes integrated into patient’s life; focus on relapse prevention |
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| Identification | Behavior is automatic: changes incorporated into sense of self |
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This patient has obesity with weight-related complications including hypertension and (likely) type 2 diabetes mellitus. However, she does not acknowledge the adverse effects of obesity and voices no readiness to institute behavioral changes (eg, diet, exercise). Counseling of patients with obesity and other lifestyle-related disorders (eg, smoking, alcohol abuse) can often be tailored to the individual patient by using a stages of change model; this patient is considered to be in the precontemplation stage.
Patients in the precontemplation stage are not ready to explore lifestyle change options or implement specific behavioral interventions. However, it is often beneficial to explore the patient's current understanding of their condition and how it can affect their future health. Patients with obesity frequently understand much about the potential health consequences; engaging in a nonjudgmental discussion of how this patient's weight affects her blood pressure and glucose may facilitate more productive conversations in future visits.
(Choice A) Although bariatric surgery is indicated based on this patient's BMI, noninvasive treatments (ie, diet, weight loss medication) are usually attempted first. Also, specific interventions are generally not discussed until the patient is ready to consider options for change.
(Choice B) Once a patient voices willingness to consider lifestyle change (ie, contemplation stage), the clinician should start introducing potential interventions in general terms, discussing the various pros and cons. However, in this case, the clinician should first encourage the patient to consider the need for lifestyle change before discussing possible interventions.
(Choice D) Many diets (eg, low-fat, low-carbohydrate, reduced-calorie blended) have been shown to produce weight loss, but most require changes in food choices, not just food quantity. Details of implementation generally would not be discussed until the patient voices some level of readiness to change.
(Choice E) Initiating a weight loss program with small, incremental goals is frequently helpful in the implementation of lifestyle change. However, setting goals is more appropriate at the time the patient is preparing to institute behavior change (ie, preparation stage).
Educational objective:
Patients in a precontemplation stage of change do not acknowledge the negative consequences of current behaviors and are not ready to implement specific lifestyle changes. Providers working with patients in the precontemplation stage should avoid recommending specific actions but instead discuss patients' understanding of their condition and its effect on their future health. A nonjudgmental discussion of lifestyle can often facilitate more productive conversations in the future.