Helping Your Patients Change
Today’s Dietitian
By Lisa Karpel, MS, RD, LDN & William A. Wolfe, MSW
Vol. 6 No.6 p. 34

Behavioral changes are difficult. Whether it’s smoking cessation or weight loss, change takes time and effort. More often than not, making a lifestyle change also entails periods of failure.

Healthcare practitioners know that getting patients to change their current practices for more healthful ones is no easy task, yet we must continue to strive for that goal. Effectively helping people change is not only important for our own personal career satisfaction—results are also expected by those who pay for our services. Insurance companies will continue to demand more proof of the cost-effectiveness of healthcare services, and cost-effectiveness is certainly measured in terms of our efficacy.

Some disturbing statistics abound: In January, the Journal of the American Dietetic Association (JADA) published research on the rates of dietary noncompliance among hemodialysis patients.1 Surprisingly, patients counseled by dietitians did not show better rates of compliance. Even more striking, the greater the knowledge a patient showed with regard to high-phosphorous foods, the less likely they were to be compliant with the renal diet.

A report in the January issue of The Journal of the American Medical Association noted that too few diabetics are making necessary lifestyle changes such as lowering fat or losing weight.2 Although insurance companies are now more likely to cover visits to dietitians for diabetes-related dietary counseling, little has improved in the way of overall blood glucose control nationwide. Data from the National Health and Nutrition Examination Survey studies showed that the percentage of diabetics achieving blood glucose and blood pressure goals is less than 12%, which is close to what it was a decade ago.

Grim statistics aside, most of us have already accumulated our own warehouse of noncompliant-patient anecdotes. Noncompliance happens and we all know it. Our well-meaning (possibly lifesaving) advice frequently goes unheeded. Obviously, handing patients diet guidelines and recipes is not enough. Yet, our time is limited and our patient loads are frequently heavy. Is it any wonder that some dietitians hover perilously close to burnout?

It is imperative that we learn how to best meet people “where they are” to reach them at all.

Why Is Changing Behavior so Difficult?
Researchers have been asking this very question for years. One theory that has been widely researched and applied to various areas is the Transtheoretical Model (TTM) of Behavioral Change, developed by James O. Prochaska and his colleagues at the University of Rhode Island’s Cancer Prevention Research Center. Often referred to simply as the “Stages of Change” model (or TTM in the literature), the theory addresses ideas such as the following:
• Behavioral changes do not occur in a linear fashion.
• People progress through predictable stages of change before reaching an action stage.
• Every stage of change is necessary because people learn from each stage.
• One intervention cannot be applied to all patients as some will be in different stages of “readiness” than others.

The various stages of readiness as described by researchers using Prochaska’s model are the following:
1. Precontemplation. Patients in this stage show no apparent desire for change. This may also be referred to as the “denial stage.”
2. Contemplation. This next stage of change is characterized by ambivalence. The patient is considering the possibility that there is a problem. A hallmark feature of this stage are “yes/but” statements (eg, “I’d like to lose weight, but I find diets too confusing to follow”).
3. Preparation. A patient in the preparation stage is intending to take action in the near future. There is usually a plan in place, such as setting up an appointment with a dietitian.
4. Action. At this stage, the patient is engaged in working toward a goal and achieving results of some sort. A patient in the action phase may be walking or checking his or her blood sugars daily.
5. Maintenance. When a patient has incorporated new behaviors into his or her lifestyle to such a degree that the behaviors feel normal, they are considered to be in maintenance. Relapse is less likely at this stage, although it may certainly occur at any point.

Indeed, relapse is entrenched within the stages of readiness. More often than not, people will experience relapse when they first try to change behaviors.3,4 Research indicates that cycling through several stages of change can happen a number of times before change sticks. It may be helpful for the practitioner to help the patient realize this when he or she is discouraged.

TTM is a well-researched model that has been validated and applied to a variety of behavioral problems, including smoking and alcohol abuse, over the past 20 years. Valid concerns about its application in the area of dietary counseling have been discussed by authors Kristal et al in the June 1999 issue of JADA: “Dietary behavior is fundamentally different from behaviors such as smoking or using drugs. Thus, creative interpretation of the stages of change construct is required in reference to diet. We always need to eat.”5

However, the authors also mention “feasible and meaningful” applications of TTM in research done by Green, where dietary interventions targeted to “stages of change” in patients demonstrated an accelerated reduction in dietary fat intake. Because TTM remains a promising theory, it should be noted that it is now “routinely incorporated into nutrition research study designs … (especially) intervention trials.”6

It stands to reason that those of us in clinical, community, and private practice should become familiar with how it works and how we can apply it in our work.

Incorporating TTM in Dietary Counseling
Perhaps you are a dietitian working in a large facility. You may regularly receive consult requests for the “repeat offenders”: dialysis patients with chronic hyperkalemia or fluid overloads or the chronic heart failure patient who binges on hot dogs. Dietary compliance (or the lack thereof) is probably discussed at rounds and meetings with some regularity.

You may even wish (as I did at times) for a large rubber stamp with the word “noncompliant” on it to save yourself the trouble of writing it in the chart.

I was introduced to Prochaska’s work by a colleague who has been a social worker for many years. I began reading the research on TTM and gradually incorporated its strategies into my daily practice. Utilizing different approaches based on a patient’s stage of readiness proved incredibly helpful not only in terms of patient compliance but also in terms of how my patients related to me.

Prochaska has been quoted as saying that most healthcare intervention programs are targeted toward people in the preparation stage, which neglects a large proportion of our patients. Many patients come through our doors knowing that something is wrong. However, many do not know how to change. Discussing the food pyramid or handing out exchange patterns may be helpful for the patient who is beyond precontemplation and contemplation. But what about the patient whose eyes glaze over the minute you enter the room?

Recognizing that a patient is in the denial phase of change is usually easy. The patient may appear disinterested or simply deny the need for intervention.

The natural tendency for any practitioner is to try and teach or convince the patient that change is necessary; however, this usually only creates more resistance. Research implies that the more confrontational a provider is at this stage, the less likely any change will occur.

A dietitian’s realistic goal in this situation is not to teach the patient carbohydrate counting but rather to take the patient from a place of disinterest and denial (“I don’t want to lose weight”) to curiosity and awareness (“Tell me more”). Motivational interviewing is a strategy that incorporates empathy and thought-provoking questions. A question such as “How will you know if it’s time to lose weight?” helps the patient begin a thought process rather than passively half-listen to a deluge of information. Even if your visits with patients are limited (as in acute care settings), meeting patients “where they are” can provide the impetus for those patients to take the next step.

The contemplation stage can be both exciting and frustrating. I have frequently utilized the Readiness to Change ruler exercise as described by Zimmerman,7 which helps patients visualize where they are in terms of achieving dietary goals. I have also drawn staircases with the various stages of readiness written under each ascending step. Interestingly, every patient I have done this with knows exactly where they are on either diagram. This has led to very enlightening discussions about the patient’s ambivalence about changing. Again, using motivational interviewing techniques prevents lecturing on my part and passivity on the patient’s end. A question such as “What do you think you need to learn about changing?” when encountering yes/but statements elicits more thought about what’s keeping the patient stuck.

The patient in the preparation stage will benefit from supportive information. Where are weight-loss classes held? Where can I start a walking program? Which books and Web sites are reliable and helpful? I find my patients want lots of information at this point and exhibit enthusiasm, even if no dietary goals have been achieved yet. Interviewing and counseling sessions should continue to avoid questions that elicit simple yes/no answers.

The action stage is one of the most wonderful but can also be one of the most fragile. Prochaska noted that during the action stage, many people feel a marked lack of support and describe their quality of life as somewhat diminished. It’s important for the dietitian to discuss high-risk situations with their patients. Relapse is quite common if the patient’s support system is lacking. A patient’s spouse, for example, might complain about the “rabbit food” she is serving at mealtimes. When I teach weight-management classes, I stress social support, such as local Take Off Pounds Sensibly Club meetings. I also have students exchange phone numbers weekly and give them assignments to call each other.

If relapse should occur, my patients do appreciate a discussion on the normal stages of change that people cycle through. Again, using the Readiness to Change ruler or creating your own a diagram is helpful; my patients tell me they feel more grounded knowing they are “somewhere,” not just floundering through a sea of conflicting emotions. Using motivational interviewing techniques, I would also ask the patient about what did and did not work on his or her journey to weight loss.

If a patient can maintain a new behavior for six months, he or she is considered to be in maintenance. If it is possible within the scope of your practice, having patients in maintenance talk to other patients (who may be in earlier stages) can be wonderfully beneficial.
TTM may be incorporated into daily dietary practice and can be helpful when discussing your patients with other healthcare providers. For example, when speaking with a doctor, you may suggest an intervention for the patient in the preparation stage: “Jim would really like you to suggest what type of exercise would be best for him.” Or, for someone in the contemplation stage: “Jane is thinking about weight loss but worries that her husband won’t be supportive. If we both discuss these concerns with her, we might get her to the next step.”

It’s important to utilize other healthcare providers because, as Zimmerman notes,7 the physician’s encouragement can take many precontemplators into contemplation mode.

Measuring rates of compliance can be difficult where nutrition counseling is concerned. Insurance companies want to see lower blood sugars and reduced cholesterol levels.

Your company may want to look at PTH (parathyroid hormone) levels. Numbers are important and we can’t get away from that. However, changes in our patients may also be measured by how often they attend weight-loss support groups, percent shifts in attitudes, overall nutrition knowledge, and other thought processes. The complexity of human behavior requires that we find other ways, in addition to the numbers, to measure progression through stages.

Change will remain difficult and our jobs will always be complex. Time with patients is limited. Yet, effective time spent with a patient reminds us of why we entered this field in the first place. That moment of connection, letting the patient know you really see and hear him or her, is truly meaningful. It’s important for us to adopt the belief that people who come to see us truly desire change—they are just not sure about how to get there.

— Lise Karpel, MS, RD, LDN, is a clinical dietitian at Lancaster General Hospital and a community health educator at the Wellness Center of Ephrata Community Hospital, both in Pennsylvania. She also has a private practice in which she specializes in weight management.

— William A. Wolfe, MSW, is a nephrology social worker at Belmont Court Dialysis, Inc. in Norristown, Pa.

References for this article are available upon request by e-mailing TDeditor@gvpub.com.

Recommended Reading

Miller WR, Rollnick S. Motivational Interviewing: Preparing People to Change. New York: Guilford Press; 2002.

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