Behavioral Assessment

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Assessment of patient motivation is a prerequisite for weight loss therapy. Weight reduction in the clinical setting represents a major investment of time and effort on the part of the health care team and expense to the patient. For these reasons, motivation for weight loss should be relatively high before initiating clinical therapy. At the same time, it is the duty of the practitioner to heighten a patient's motivation for weight loss when such is perceived to be of significant benefit for risk reduction. This can be done by enumerating the dangers associated with persistent obesity and by describing the strategy for clinically assisted weight reduction. For patients who are not motivated (or able) to enter clinical weight loss therapy, appropriate management of risk factors (e.g., high serum cholesterol, hypertension, smoking, and type 2 diabetes) is still necessary. Sustained weight reduction may facilitate control of cardiovascular risk factors and delay the onset of type 2 diabetes.

Clinical experience suggests that health care practitioners briefly consider the following issues when assessing an obese individual’s readiness for weight loss:

“Has the individual sought weight loss on his or her own initiative?”

Weight loss efforts are unlikely to be successful if patients feel that they have been forced into treatment by family members, their employer, or their physician. Before initiating treatment, health care practitioners should determine whether patients recognize the need and benefits of weight reduction and want to lose

weight.

“What events have led the patient to seek weight loss now?”

Responses to this question will provide information about the patient’s weight loss motivation and goals. In most cases, individuals have been obese for many years. Something has happened to make them seek weight loss. The motivator differs from person to person.

“What are the patient’s stress level and mood?”

There may not be a perfect time to lose weight, but some are better than others.

Individuals who report higher-than usual stress levels with work, family life, or financial problems may not be able to focus on weight control. In such cases, treatment may be delayed until the stressor passes, thus increasing the chances of success.  Briefly assess the patient’s mood to rule out major depression or other complications. Reports of poor sleep, a low mood, or lack of pleasure in daily activities can be followed up to determine whether intervention is needed: it is usually best to treat the mood disorder before undertaking weight reduction.

“Does the individual have an eating disorder, in addition to obesity?” Approximately 20 percent to 30 percent of obese individuals who seek weight reduction at university clinics suffer from binge eating. This involves eating an unusually large amount of food and experiencing loss of control while overeating. Binge eaters are distressed by their overeating, which differentiates them from persons who report that they “just enjoy eating and eat too much.” Ask patients which meals they typically eat and the times of consumption. Binge eaters usually do not have a regular meal plan; instead, they snack throughout the day. Although some of these individuals respond well to weight reduction therapy, the greater the patient’s distress or depression, or the more chaotic the eating pattern, the more likely the need for psychological or nutritional counseling.

“Does the individual understand the requirements of treatment and believe that he or she can fulfill them?”

Practitioner and patient together should select a course of treatment and identify the changes in eating and activity habits that the patient wishes to make. It is important to select activities that patients believe they can perform successfully. Patients should feel that they have the time, desire, and skills to adhere to a program that you have planned together.

“How much weight does the patient expect to lose? What other benefits does he or she anticipate?”

Obese individuals typically want to lose 2 to 3 times the 8 to 15 percent often observed and are disappointed when they do not. Practitioners must help patients understand that modest weight losses frequently improve health complications of obesity. Progress should then be evaluated by achievement of these goals, which may include sleeping better, having more energy, reducing pain, and pursuing new hobbies or rediscovering old ones, particularly when weight loss slows and eventually stops.

The following critical factors must also be evaluated to determine patient motivation:

• Reasons for weight loss—What is the extent of the patient's seriousness and readiness to undergo a sustained period of weight loss at this time? What is the patient's current attitude about making a life-long commitment to behavior change?
• Previous history of successful and unsuccessful weight loss attempts—What factors were responsible for previous failures and successes at weight loss or maintenance of normal body weight?
• Family, friends, and work-site support—What is the social framework in which the patient will attempt to lose weight, and who are the possible helpers and antagonists to such an attempt?
• The patient's understanding of overweight and obesity and how it contributes to obesity-associated diseases—Does the patient have an appreciation of the dangers of obesity, and are these dangers of significant concern to the patient?
• Attitude toward physical activity—Is the patient motivated to enter a program of increased physical activity to assist in weight reduction?
• Time availability—Is the patient willing to commit the time required to interact with health professionals in long-term weight loss therapy?
• Barriers—What are the obstacles that will interfere with the patient's ability to implement the suggestions for change?
• Financial considerations—Is the patient willing to pay for obesity therapy? This may include having to pay for travel to the medical facility, time lost from work, and paying for professional counseling that is not covered by insurance.

One of the most important aspects of the initial evaluation is to prepare patients for treatment. Reviewing patients' past attempts at weight loss and explaining how the new treatment plan will be different can encourage patients and provide hope for successful weight loss. It is helpful to discuss the proposed course of treatment and describe necessary behaviors, such as keeping diaries of food intake and physical activity.

Finally, given the social stigmatization that obese patients often feel, even from health care professionals, the initial evaluation is an opportunity to show the patient respect, concern, and hope.  A patient who has shared feelings about being overweight and previous attempts to lose weight with a sympathetic listener may be more willing to consider new ideas and information. A partnership in which the patient feels supported and understood can help to sustain the necessary motivation for the difficult task of weight loss and maintenance.