The family physician advising the patient about improving diet and lifestyle must specify the behaviors needed (rather than outcomes), help build the patient's behavioral change skills, address factors impeding change, and have an interactive discussion.
Specify Behaviors, Not Just Outcomes
Many chronic conditions have dietary implications, and dietary change is required for the condition to improve. For example, obesity involves calorie reduction; diabetes involves changes in food types eaten, portions, and spacing of eating episodes; and hypertension often involves sodium restriction. Thus, it is important to focus on the behavior necessary (e.g., reducing intake of simple carbohydrates) to reach the outcome (improved HbA1c levels). Often, dietary advice involves the patient being told to do the outcome, such as "lose some weight" or "improve A1c." Although important goals, these should not be confused with what action a patient can take. A patient cannot stand still and lose weight but can only change eating patterns and increase physical activity (behaviors). In communicating with patients, it is important to state not only the desired outcome and why (e.g., "It is important to get your hemoglobin A1c below 7% so that you can reduce the chance that you will have complications from your diabetes, such as loss of vision or amputation"), but also to discuss how the patient might accomplish that outcome (e.g., "Eating a healthy diet and increasing physical activity can improve A1c. Which of these would you like to talk about today?").
A second common problem with diet counseling is that the focus is often on the patient acquiring knowledge rather than learning the skills for change. Patients who are critically ill need specific instructions on dietary restrictions for their condition. However, most patients who need diet counseling (e.g., those with hypertension, obesity, type 2 diabetes) need to know how to change their habits more than specific details of "dieting dos and don'ts." Too much information also overwhelms most patients, who begin to feel helpless to make all these changes correctly. Instead, encourage patients to consider how they will make the diet changes needed. Use a step-wise approach; start with small goals in short time increments and build to long-term goals so that patients may gain confidence in their ability to be successful with a new diet plan. Research shows that patients are best able to change behavior when the following elements are incorporated into the plan:
• Readiness to change. Patients are in different places with regard to their readiness to change (see Chapter 7). Some are ready to make a change immediately, some are reluctant and cannot decide, and others have tried repeatedly and failed. The family physician's goal is to move the patient to the next logical step (Prochaska et al., 1992).
• Goal setting and tracking. Proper goal setting and knowing the patient's current state can facilitate successful change by encouraging confidence in the ability to change. Start off with a small, attainable goal and build over time (Locke et al., 1981; Strecher et al., 1995).
• Relapse prevention. Patients who have an active plan for avoiding temptation and returning to past behaviors are much more successful than patients who have not planned coping strategies to use during tempting situations (Larimer et al., 1999; Marlatt and George, 1990).
• Support. Consider how people and environments can support the patient making changes.
These strategies collectively affect self-efficacy and perception of the patient's ability to make successful change in a specific area (Bandura, 1977, 2004).
Many behavioral theories describe why patients act appropriately or not in regard to healthy behaviors, but in the daily practice of medicine, it is useful to break this into a simple and workable system. Motivational interviewing shows great promise as a technique for encouraging behavior change discussions with patients regarding diet improvement (Burke et al., 2003; Thorpe, 2003; vanWormer and Boucher, 2004). Physicians should consider two main factors affecting patient motivation for changing a behavior: importance and confidence. Importance is the priority the patient places on the behavior change in question. "How important is it that I make this change?" Confidence is the patient's perception that he or she can actually execute the change. Both are needed. When discussing dietary change with patients, it is important both to engage the patient in considering his or her level of importance and confidence relating to the behavior or task in question and to encourage the patient to consider how the importance and confidence are preventing progress toward a goal, as well as what specific barrier to change (Miller and Rollnick, 2002; Rollnick, 1996). Factors that influence importance include the following:
• The expected benefit of the change and the value of that benefit
• Competing priorities
• How others view the behavior, and how much the patient values their views
• Cues in the environment
• Perception of connection to a healthy outcome (how severe, how likely)
• Quality of available information
Factors that influence confidence are as follows:
• Success of options for change (does anything work?)
• Past experiences with change
• Support from others
• Resources and skills needed
• Supportive environment(e.g., foods available, social situation)
It is important to communicate dietary information in a way tailored to each patient by considering each patient's specific circumstances, readiness to change, and motivation. Patients often tire of a canned lecture. Consider the patient an expert on him/herself, and ask open-ended inquiring questions, then incorporate the patient's response into a plan. In general, try to focus on encouraging your patient in the process of change rather than the emphasis on specific foods or details of diet instructions that they can read or learn about on their own.
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