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Facilitating Lifestyle Behavioral Changes
Encounters are more effective if they begin by determining what the patient wants to know and accomplish and what you can do to be of assistance.
By Marion J. Franz, MS, RD, CDE
The key to assisting patients with making effective lifestyle changes is to develop a positive relationship with them while finding ways to help them take responsibility for how and when to change eating and activity habits. Unfortunately, this often requires more time than busy practitioners have available. The question then becomes, when time is limited, what can practitioners do to facilitate patients taking responsibility for change?
Diagnosing the problem and knowing what lifestyle changes would be helpful is usually the easiest piece in the puzzle. Often, the first solution for busy professionals is to give advice, usually information or directives. But information or advice rarely results in patient behavioral changes. Patients with diabetes reported that support from their physician, even if brief, was the most important part of a lifestyle change intervention.1 This article reviews research on how to facilitate and support behavioral changes and provides suggestions as to how busy practitioners can assist in this process.
TRANSTHEORETICAL MODEL OF INTENTIONAL BEHAVIOR CHANGE
Patients differ in their readiness to make behavior changes and therefore, the first step is to determine their interest and willingness to make changes in their lifestyle. Prochaska and colleagues2,3 have developed a general model of intentional behavior change—The Transtheoretical Model of Intentional Behavior Change, commonly referred to as Stages of Change (Table 1). It includes a sequence of stages along a continuum of behavior change and can be used to help professionals understand their patients' readiness to change behaviors. Whatever stage the patient is in, however, establishing rapport is a crucial first step. Encounters are more effective if they begin by determining what the patient wants to know and accomplish and what you can do to be of assistance.
Different intervention strategies are needed for individuals at different stages of the change process. Many patients are not ready to make dramatic lifestyle changes during an initial encounter. Of people in need of lifestyle change, 80% are reported to be in the precontemplation or contemplation stages.3 Although professionals often assume that patients are ready for action, in actuality, they are still stuck in precontemplation. Most education and counseling approaches are targeted to individuals in the preparation and action stages. Motivational interventions may work best with individuals who are in the earlier contemplative stages, whereas goal setting and specific skill-training interventions may be most appropriate for individuals who have decided to change. Relapse and recycling through the stages occur frequently as individuals attempt to modify behaviors.2
Precontemplation. Patients who are in the precontemplation stage usually do not believe they are at risk for any of the complications of diabetes. Although they may verbalize that they have diabetes, internally, they may not have personalized the disease. Therefore, the first step is to personalize the risks. Practitioners can do this by communicating information about lifestyle and diabetes risks. A discussion about the benefits and barriers to improved glucose control will likely be of more benefit than, for example, providing guidelines on how to exercise. Comparing target medical goals with a patient's data can help him or her determine whether making lifestyle changes is important.
The information is not intended to "scare" but rather to convince them they are at risk and, more importantly, there are actions they can take to greatly decrease these risks. Hopefully, this can be accomplished in an initial encounter but if not, needs to be reviewed with the patient until he or she can accept the reality of the need to make lifestyle changes.
Patients who hold two important beliefs are reported more likely to begin self-management behaviors:4 (1) they believe diabetes to be serious and (2) they believe they have diabetes and that their own actions can make a difference.
Contemplation. Patients who are in contemplation have accepted the fact they have a problem and are thinking about starting to make some lifestyle changes. Asking patients what they wish to learn or gain from the encounter is a good introduction to the session. Time may not be available for an in-depth discussion, but often professionals have written booklets or brochures in their office that can be provided to the patient. A note can be made in the chart about the information given, and at the next encounter, questions the patient may have can be answered.
Asking patients if there are behaviors they can change to assist in meeting their goals and asking what is the most difficult aspect of lifestyle change can generate energy. This is particularly important for individuals who have lived with diabetes for long periods of time and need renewed enthusiasm to continue living well with diabetes. The techniques of motivational interviewing5 given in Table 2 have proved helpful for professionals in their encounters with patients in the precontemplation and contemplation stages.6
Motivational interventions, such as an article on the dangers of high blood glucose levels, may work best with individuals who are in the earlier contemplative stages, whereas, specific skill-training interventions, such as learning about carbohydrate counting, may be more appropriate for individuals making lifestyle changes.
Preparation. Patients in the preparation stage have made a commitment to take action within the next 30 days and usually have started to make small behavioral changes. A person's self-efficacy and self-confidence in making and maintaining a change is a significant predictor of later adherence.7 Focusing on lifestyle strategies that are feasible and realistic and assuring the patient that he or she can achieve these goals increases the patient's confidence in his or her ability to make crucial lifestyle changes. It is important that a start date be set for making agreed upon changes.
Action. The action stage is when the patient is ready for skill training and education. This is an appropriate time to ask patients if they think they can make the important lifestyle changes by themselves, or if it would be helpful to receive help from professionals. Referrals can then be made to registered dietitians for medical nutrition therapy or diabetes education programs for self-management skill training.
Behavior modification is a method for systematically modifying eating, physical activity, or other behaviors. Techniques that patients who have made lifestyle changes find to be most helpful have been reported.8 Although this research has not focused only on individuals with diabetes, those making lifestyle changes for other reasons face similar challenges. Helpful techniques include self-monitoring, setting goals, stimulus control, contingency management, cognitive restructuring, preventing relapse, and stress management (Table 3).9
SELF-MONITORING RECORDS
Self-monitoring is always rated by participants as the most helpful strategy for behavior change. The primary purpose of self-monitoring is to raise awareness. If an individual is going to change eating and physical activity habits, it is important to know what one is eating and to know one's activity level. The typical way to raise awareness of habits is for patients to keep a diary in which they write down what they eat, the number of minutes they are physically active, and their blood glucose tests. Although individuals often underestimate food intake and overestimate activity, it really doesn't matter. The primary purpose of monitoring is to raise awareness, not accuracy of recording.
Research also reports that self-monitoring is the most important of all behavioral strategies. For example, in the DPP (Diabetes Prevention Program), the frequency of self-monitoring was related to success at achieving both the physical activity goal and the weight-loss goal.10 In a 1-year trial, individuals who frequently recorded their food intake lost more than twice as much weight as those who did so infrequently.11 Frequent monitoring of food intake and weight by participants in the National Weight Control Registry was an important predictor of successful weight loss maintenance.12
Asking patients to keep food and activity diaries can, therefore, assist patients as they struggle to make lifestyle changes. If patients are asked to keep records, it is important to note this in their charts. That will remind the practitioner to ask about the records at the next visit. Often, patients will keep records from 3 days of a week—2 weekdays and 1 weekend day.
Busy practitioners rarely have much time to review these records. Two issues can be looked at quickly and commented on. First, does the patient eat breakfast? For example, participants in the National Weight Control Registry report eating breakfast every day.13 This is in contrast to many dieters who skip breakfast (and lunch) and then eat uncontrollably from late afternoon on. Omitting breakfast is also reported to impair fasting lipids and postprandial insulin sensitivity.14 The second issue is beverage consumption. Is the patient consuming regular soft drinks or large amounts of fruit juices? Water and skim milk should take precedence over consumption of beverages with more calories.15,16 Comments on the importance of eating regular meals with consistent amounts of carbohydrate can also be made.17
Realistic goals. Behavioral goals are often short-term (days or weeks) and related to lifestyle changes (ie, food and eating behaviors, physical activity, self-monitoring of blood glucose). These goals must be set jointly between the patient and the professional. Common behavioral goals are consistent and appropriate carbohydrate choices, regular physical activity, correct medication dosage, and blood glucose monitoring as needed. Goals should be specific, written in behavioral language, and realistic for the person with diabetes. Accomplishing modest food/nutrition or physical activity goals often improves self-esteem and serves as encouragement to try new ones. Setting unrealistic goals frequently results in disappointment, discouragement, and ultimately failure.
Nutrition therapy. Nutrition therapy that is designed around a patient-centered framework is often more time-consuming and challenging than traditional approaches, but its chances for success are greater. Simply delivering information is not enough to ensure action. Patients also need skills to help them make behavioral changes necessary to ensure the goals and effectiveness of medical nutrition therapy.
Maintenance. Patients in maintenance are striving to stabilize their behavior change and to avoid relapse. Successful self-management involves an ongoing process of problem solving, adjustment, and readjustment. Individuals must be able to anticipate and deal with the wide variety of decisions they face on a daily basis. It is essential that support from family and friends is provided in the right balance—the right amount to promote adherence, but more than desired amounts negatively affects these behaviors.18 And just as support from family and friends is important, continuing education and support from professionals is also essential. Techniques to assist individuals maintain behavior change have also been identified and are listed in Table 4.19
SUMMARY
Even though time may be limited, support from physicians and other health practitioners is essential if patients are to be successful in making lifestyle changes. Table 5 is a summary of the Stages of Change that patients can be in and suggestions for effective interventions shown to assist patients in making change that can be implemented by busy practitioners. Other suggestions include:
- Asking patients to keep food and physical activity records. This has been shown to be the number one strategy used by patients to make change.
- Reviewing goals, problems, and solutions.
- Ask patients what they need to do and what they can do.
- Promote realistic expectations.
- Develop (and record) realistic lifestyle change goals with the patient—not weight loss goals—based on readiness to change.
- Giving positive feedback and encouragement, never criticizing.
- Providing office follow-up: ask for food and activity records and review goals.
- Identifying systems in the community that can support (and if needed, counsel) patients on problem-solving skills and decision-making strategies.
Marion J. Franz, MS, RD, CDE is a nutrition/health consultant with Nutrition Concepts by Franz, Inc., Minneapolis. She is a member of the Review of Endocrinology Editorial Board and may be reached at MarionFranz@aol.com; phone: 952-941-6761; or fax: 952-041-6734.
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