A M Y L O C K E , M D , F A A F P , A B I H M

HEALTH BEHAVIOR CHANGE: CASE DISCUSSIONS IN NUTRITION

RECOMMENDED PRACTICE CHANGES

1. Adequately assess patients’ current dietary habits

2. Assess patient specific barriers to optimal nutrition

3. Use motivational interviewing to move patients towards

healthier options

• Use SMART goals

4. Work as a part of a team to provide practice-based

counseling and community-based resources to help

patients achieve and maintain a healthy lifestyle

BARRIERS TO PROVIDING ADVICE

• Time

• Priorities for the visit

• Expertise/Feelings of inadequacy

• Perception of efficacy

• Lack of referral options

• Stigma/negative physician attitudes

DEVELOPING A CUSTOMIZED PLAN

Detailed History

Review the

options

Realistic short-and long-term goals

Engage team

Reassess

FINDING MOTIVATION

• What motivates?

• What are goals?• Lose weight?

• Lower blood pressure? Cholesterol? Sugar?

• Fall less?

• Be stronger?

• Feel better?

• Live longer?

MOTIVATION: WHAT DOESN’T WORK

• Brief one-time educational intervention

• Unrealistic goals

• Guilt

• Recommend against exercise due to chronic

disease

• Focus on dramatic weight loss

WHERE TO BEGIN?

• Change takes time

• Think of a goal you accomplished

• Set small concrete goals

• Write them down and commit to someone else

• Get someone to check in on progress

• Can be office, friend, family, etc.

• Track success

SOLUTIONS

• Meet patients where they are

• Simple messages

• Focus on positives

• (what to do more of)

• Lead by example

• SMART Goals

MOTIVATING INDIVIDUALS WITH CLEAR GOALS

• Health and wellness over weight loss• Feel better, have more energy

• Short term

• Positive

• Tailored: start with one step

• Play: What is fun?

• Self Monitoring: tracking

• Each day is a new day

• Close follow-up

SMART GOALS

• Specific

• Measurable

• Achievable

• Realistic

• Time-bound

Make a list of meals for the week with a shopping list each

Sunday so that I have food in the house to make dinner each

night without going to the store

CASE: CHIEF COMPLAINT

• Wants to loose weight

HISTORY OF PRESENT ILLNESS

• 45 yo woman with with a recent diagnosis of pre-

diabetes presents with BMI of 30 and a desire to loose

weight. She is here today to discuss. She has tried

dieting in the past and after initial weight loss, she

regains more.

HISTORY

• PMH: Seasonal allergies

• Meds/OTC: Flonase, Vitamin D

• Allergies: Penicillin

• Family History:

• Father: HTN

• Mother: breast cancer at 70

• Sister: depression

SOCIAL HISTORY

• Lives with her husband and three kids ages 7, 10 and

15.

• Minimal alcohol

• No tobacco or other drugs

• College degree, works as a middle school teacher

REVIEW OF SYSTEMS

• Some fatigue, tired when wakes up

• Occasional headaches

• Congested in Spring

PHYSICAL EXAMINATION

• Obese woman in no apparent distress

• Exam is otherwise unremarkable

• BP 125/79

• BMI 32

• A1C 5.8

• Lipids: Total Cholesterol 195, TG 160, HDL 45, LDL 98

LIFESTYLE HISTORY

• Nutrition: eats some fruits and veggies; cooks at home 3

nights a week

• Physical Activity: on feet at work; plays with kids on

weekends; walks dog

• Sleep: 6 hrs per night

• Stress: work balance; child care

• Social Connection: well connected with family and

friends

ASSESSMENT

• Obese woman with pre-diabetes interested in weight

loss. Some fatigue and headaches. Diet quality is

unclear. Minimal physical activity and insufficient

sleep. Significant stressors. Good social support.

PLAN

• What would you like to do?

• Who do you want on your team?

ASSESSING DIETARY HABITSWHAT I S THE PAT IENT EAT ING?

LIFESTYLE HISTORY

• Nutrition:

• Physical Activity:

• Sleep:

• Stress:

• Social Connection:

• Screen time:

ASSESSING DIETARY HABITS

• Free form discussion

• 24 hour recall

• 24-72 hr diet diary

• Specific questions:

• Frequency cooking, eating out, assess barriers

QUICK NUTRITION HISTORY

• Fruits and veggies

• Eating out

• Beverages

• Snacks

• 24 hr food recall

• Happy with food eaten?

• Cooking skills

• Time and money constraints

TAILORING THE MESSAGE

• Fruits and veggies

• Healthy fats

• Cut back on fast food

• Limit sweet beverages

FOOD RECALL EXERCISE

• In the next few minutes:

• pair up

• take a 24 hour food recall with your partner

• Don’t forget snacks and beverages

• switch

DEBRIEF

• Issues that came up?

• How do you interpret the results?

• What do you do next?

ASSESSING BARRIERSWHAT ARE THE ROADBLOCKS?

• Food knowledge

• Cooking skill

• Food prep interest

• Taste preference

• Family expectations

• Recognition of satiety

• Mindless eating

BARRIERS: INDIVIDUAL

• Ability to read food labels

• Financial/food availability

• Time management• Hours worked

• Child care

• Other activities (i.e. TV)

• Emotional eating

BARRIERS: SOCIETAL

• Industry/lobby

• Advertising

• Subsidies

• Normalcy

• Bad food everywhere

• Obesity commonplace

• Food availability

• Food deserts

ASSESSING BARRIERS ROLE PLAY

• In pairs, one person is the patient and the other the

physician

• Stay in your role as you discuss roadblocks

• Have the “patient” rate their likelihood of being

able to make the change (1-10)

• Ask what makes them choose the number they

chose rather than a lower number

DEBRIEF ROLE PLAY EXERCISE

• Share what worked and what didn’t work

• As the patient, how did you feel?

• As the physician, what could you have done

differently?

MOTIVATING CHANGEHOW DO WE DO SOMETHING DIFFERENT?

MOTIVATING CHANGE EXERCISE

• In pairs, one person is the patient and the other the

physician (switch from last exercise)

• Stay in your role as you discuss setting a SMART goal

SMART GOALS

• Specific

• Measurable

• Achievable

• Realistic

• Time-bound

Bike 30 minutes three times a week at the park near my house with my neighbor after dinner

DEBRIEF ROLE PLAY EXERCISE

• Share what worked and what didn’t work

• As the patient, how did you feel?

• As the physician, what could you have done

differently?

USING RESOURCESWHO CAN HELP?

BUILDING THE TEAM

• The office

• The health system

• The community

• The country

• Physician

• APRN/PA

• Nurse

• Medical Assistants

THE OFFICE TEAM

• Pharmacist

• Dietician

• Social Work

• Psychology

• Health Coach

NEW PROGRAMS

• Shared medical visits

• Nurse/dietician visits with T/G codes

• Comprehensive Lifestyle Programs

HEALTH SYSTEM PARTNERS

• Specialties: cards, endocrine, ortho, etc.

• Disciplines: PT, health coaching, dieticians, public

health, pharmacy, psychology

• Human Resources

COMMUNITY PARTNERS

• Community foundations

• Grocery stores

• Culinary schools

• Recreation centers (i.e. YMCA)

• Community gardens

• City urban planners

• My Fitness Pal

• Spark People

• Fitbit

• MyNetDiary

• My Plate

APPS

• Sage Project

• ShopWell

• Nutrients (Foodle)

• HealthyOut

• Lose It

RESOURCES FOR PATIENTS

• Harvard School of Public Health

• www.nutritionsource.org

• Ending the Food Fight, David Ludwig

• www.endingthefoodfight.com

• Mindless Eating: Why We Eat More Than We Think, Brian Wansink

• www.mindlesseating.org

• Many apps and websites

• ABE’s for Everyone

• My Fitness Pal, Sparkpeople, etc.

• The Hunger Within, Marilyn Migliore

WHAT CAN YOU DO?

• Feed yourself and those

you love with healthy

food

• Focus on food over

nutrients

• Learn to cook

• Move for fun

• Lobby for change

• Nationally

• Locally

• Patients

• Meet people where they are

• Talk about lifestyle with patients

• Set large and small goals