How to approach healthy lifestyle changes.
Why do self-change attempts fail?
Expectations often exceed what is feasible
People often predict that they will change more quickly and more easily than
is possible
People overestimate their abilities in many domains and are unaware that they
are inaccurate
People often believe that making a change will improve their lives more than
can reasonably be expected
(Verbatim from up-to-date, I just liked it).
Stages of motivation
These seem to be pretty standard. They are particularly applied to cigarettes and drugs
of addiction.
Precontemplation — The patient states he/she is not ready to change. Keep
asking them.
Contemplation — The patient is considering change at some point in the
future. Encourage them to commit to change in a specific timeframe.
Determination — The patient is considering cessation soon and is engaging in
some behaviour aimed at making the desired change.
Action — The patient has changed their behaviour.
Maintenance — The patient has maintained changed behaviour for at least six
months.
Encouraging behavioural change
Ask patients what they think would improve their health. This reduces the time to
assess the patient’s current situation and helps focus on things the patient might be
more willing or able to change. Also identify strengths to try to encourage and build
on.
Assess the current behaviour with an appropriate tool e.g. 24 hour food diary with
prompting (―What did you eat or drink next? Did you have anything else at the
time?‖).
Assess contributing behavioural factors e.g. work constraints, social and family
factors, patient’s health goals. Encourage the patient to seek support for the changes
from their family and friends. Tailor the advice to the situation of the patient.
Strategies promoting behavioural change:
Problem-solve: identify obstacles with the patient and work out how to
overcome them. Consider wider lifestyle changes to support the new
behaviour e.g. start exercise or meditation when quitting smoking.
Enlist their social supports
See the patient frequently (or get someone else to see them) to reinforce the
changed behaviour – effective both for diet change and smoking cessation.
Educate the patient about good behaviour (what is good behaviour, what are
the rewards, what are realistic goals), the consequences of their current
behaviour (risks), what the process of change might be like. It appears that
more information makes people more likely to change – even if you are telling
them that they currently have no symptoms.
Control the stimuli that activate the undesired behaviour and try to disrupt
triggers e.g. stop eating dinner in front of the TV, avoid smoking in the home
or car.
Give them money
The patient should self-monitor – it greatly improves outcomes in dieting and
is also applicable to smoking
Modify the behaviour itself, where appropriate e.g. slow down eating
Get the patient to make a contract about what they will do.
Consider behavioural tools such as assertiveness training, encouraging
positive self-talk
Bear in mind referral to psychologists or counsellors for patients with severe problems
or complicating psychiatric disorders.
The process may be lengthy e.g. weight loss after 20 week program is more than
double that after 8 week program.
Relapse is common and shouldn’t be a barrier to trying again.
Consent to medical treatment.
Doctors cannot treat without consent except in emergencies (they’re going to die
because of something you should have just done) and minor treatments (administering
a drug they’ve already been prescribed).
Patients can consent according to their capacity: the extent to which they can
understand, retain, believe, evaluate and weigh relevant information. If the patient
doesn’t have capacity in a particular incident, someone else must make the decision
(long list).
The doctor must give the patient adequate information that is appropriate to their
circumstances e.g. a bikini model needs to know about the risk of keloid scarring
when she has cosmetic excision of naevi.
Material risks: a reasonable person would attach significance OR medical practitioner
should reasonably be aware that the patient would attach significance to it.
Rule of thumb for material risks:
slight but common
rare but severe adverse outcomes.
References
Uptodate. Dietary and nutritional assessments in adults. Behavioural strategies in the
treatment of obesity. Smoking cessation counselling strategies in primary care.
Management of smoking cessation in adults.
Consent to medical treatment. Australian Family Physician Vol. 34, No. 5, May 2005