I am really drawn to the psychological side of dietetics, what got patients where they are now and why they are struggling to overcome their current state. Whether it be eating disorder, obesity or struggling to adapt to a new diagnosis which may change their eating pattern I find it very interesting and rewarding to counsel patients and try to tackle the root of the problem. I therefore thought it would be good to share some tips on behaviour change that I learnt when on clinical placement and through my degree.
Below is the ‘cycle of change’ we perceive patients to go through whenever they are faced with the challenge of changing/adapting their dietary and lifestyle habits:
- Pre-contemplation – the patient does not see any problem in their current behaviour/diet/lifestyle and has not considered there might be better alternatives.
- Contemplation – the patient is ambivalent whether to stay with their existing behaviours or to try changing to something new?
- Preparation – the patient is taking steps to change, usually in the next month or so.
- Action – the patient has made the changes and are living the new set of behaviours.
- Maintenance – the change has been integrated into the person’s life.
- Relapse is a full return to the old behaviour. This is not inevitable, but is likely and should not be seen as failure. Often people will relapse/lapse several times before they finally succeed in making a permanent change to a new set of behaviours. It is important to explain this to the patient so they do not feel alone and that they have failed if they do lapse, it is perfectly normal to do so.
It would most typically be around the contemplation/preparation stage in which we first see patients. However some patients may be in the pre-contemplation stage, simply referred to the dietitian by their GP without any want to make changes, and in contrast some may already be in the action stage which is typically seen in patients who have suffered, or observed in their immediate family, some kind of health scare. It is imperative to be able to recognise as a dietitian at which stage the patient is in when they come to the first consultation as to what clinical plan and goals you will set for them and work to achieve.
The key attributes of the dietitian when assessing a patient in any behavioural change setting are:
- Exploring the patient’s readiness to change (what stage they are at)
- Facilitating goal setting (tailored to their lifestyle and needs)
The tools for changing behaviour are:
- Changing unhelpful behaviours
- Initiating new behaviours
- Self monitoring food intake and body weight (food/feeling diaries, activity diary)
- Goal setting
- Knowing your triggers to lapse/relapse
- Stimulus control
- Problem solving
- Relapse management
- Support from others
When assessing a patients readiness to change, in a weight loss situation, some of these questions are good to ask:
- How important is it that you lose weight at this time?
- Does your weight bother/affect you?
- Are you aware of the health risks of being overweight?
- Is your decision to lose weight you own, or for someone else?
- Who, if anyone, is supportive of your decision to lose weight? What kind of support would you like to have?
- Are there any events in your life at this time that might make losing weight especially difficult?
- If now is a convenient time to lose weight, what would it take you to be ready to lose weight? When do you think you might be ready?
At this point it can also be helpful to draw up a ‘pros and cons’ chart comparing them staying the same to them making changes. This will help you gauge whether the patient is ready, and will also help them to assess whether they feel ready. If you or they feel that at this time they are not ready to make the necessary changes, this is ok. The seed has been planted for the future, and you can give them some general healthy eating for weight loss advice without getting into the behavioural change techniques. Give them your contact details and let whoever referred them to you know what has happened.
If the patient is ready to make changes however, then a variety of things can be discussed during each clinic appointment. Such as:
- Healthy eating (it is good to get a food diary completed for 3-5 days, and perhaps get them to record their feelings whilst eating and reason for eating as well. Whether it be because they are hungry, bored, upset, socialising, it is good to get an idea of daily habits)
- Plan goals, small and realistic (we are aiming for long term weight loss and then maintenance, not a sudden large weight loss)
- Discuss triggers for eating and coping strategies to overcome the triggers
- Challenging unhelpful thoughts and feelings
- Recognising hunger, and distinguishing it from boredom/emotional eating. Developing distraction techniques
- Self esteem
- Food labelling recognition, what to look out for when shopping
- Recipe modification, changing what they have at home into something healthier
- Eating out and socialising techniques (focus on alcohol/drinks as well)
- Strategies for long term weight maintenence
- Review and reflect in each clinic what has been successful and what hasn’t
So as not to make an incredibly long post, I shall focus in more depth in another post on some tips for weight loss, such as distraction techniques and recognising hunger. I hope this has been interesting!