Because overweight and obesity typically coexist with type 2 diabetes,weight management counseling is an integral function of diabetes clinicians. However, the task can be daunting with the limited time and resources available and with patients who vary in their attitudes, abilities, and cultural backgrounds. Furthermore, diabetes clinicians differ in their skill sets and competency regarding delivery of obesity care.
The cornerstone of treatment for overweight and obesity is lifestyle intervention, which involves counseling on diet, physical activity, and behavior.1 Although some clinicians may lack confidence in their diet and nutrition background,others may feel challenged giving exercise advice, and others still may not know what to do when stress interferes with their patients' weight loss efforts. To improve confidence in counseling skills, clinicians would benefit from using an efficient, targeted approach that is easy to understand and follow, is comprehensive, covers the three aspects of lifestyle modification,and addresses each patient's individual needs. A new weight management counseling method that accomplishes these goals is the Lifestyle Patterns Approach.
Pattern recognition, also known as heuristics or intuitive thinking, is an innovative approach to counseling.2 Pattern recognition is familiar to diabetes clinicians when reviewing the relationship between a patient's blood glucose, meals, and medication administration. Adjustments in meals and medications are made after reviewing a patient's blood glucose patterns. For obesity care, diet, physical activity, and behavioral counseling are adjusted based on a patient's lifestyle patterns. This is the basic premise underlying this new counseling method. Figure 1 depicts a lifestyle patterns organizational chart showing the seven lifestyle patterns in each of these three dimensions.3
These 21 patterns were developed intuitively after treating thousands of overweight patients during the past 25 years. By taking a previously validated 50-item questionnaire, patients find out, for example, if their eating pattern is that of a Meal Skipper, a Convenient Diner, or a Hearty Portioner; if their exercise pattern is that of a Couch Champion, an All-or-Nothing Doer, or an Uneasy Participant; and if their coping pattern is that of a People Pleaser, a Fast Pacer, or an Overreaching Achiever.4 The qualitative lifestyle pattern names help clinicians connect quickly with patients. “You pegged me,” is a frequent comment clinicians hear when using this approach. And feeling understood is often the springboard for an empathetic and therapeutic clinician-patient relationship.5
The overall goal in weight loss counseling is to help patients consume fewer calories and eat more healthfully. However, patients have different obstacles in their way. Lifestyle pattern identification helps to identify behavioral obstacles. Some people travel a lot and depend on restaurant food for their meals, whereas others eat healthfully during the day but become nighttime nibblers when they are relaxing at home. Identifying a patient's particular struggles when it comes to eating will help clinicians focus their counseling. How and when a patient eats can be as important as what and how much they eat.
Regarding exercise, knowing the recommended exercise guidelines for general health, weight loss, and weight maintenance is important, but it does not help personalize this information to patients sitting in a clinic office. Some patients may want to exercise but do not have the time, whereas others are all-or-nothing type exercisers, and still others have a functional limitation that affects their ability to exercise. Knowing the attitudes and motivations behind your patients' struggles with becoming more active gives clinicians a clearer picture of how to help each particular patient.
The coping aspect of lifestyle patterns counseling refers to how people view themselves, relate to others, and cope with stress. Often, clinicians are less comfortable addressing this area of weight loss counseling, and yet in our research, this is the most problematic dimension of weight control as identified by patients. In a study of 335 overweight patients in a clinical setting, all seven coping patterns were endorsed by > 50 % of the patients,compared to five eating patterns and three exercise patterns.6 Clearly,patients need help in this area. Using principles of cognitive behavioral therapy, clinicians are able to help their patients develop more positive coping skills by assisting them, for example, to tackle their emotional eating behaviors, lessen their tendencies to procrastinate, or put their self-care higher up on their to-do list.
After the interactive questionnaire is scored, patients can view the results, which consist of three separate lifestyle pattern profile graphs in the dimensions of eating, exercise, and coping. A sample eating patterns profile graph is shown in Figure 2. Similar exercise and coping pattern profile graphs are also displayed for patients who complete the questionnaire. A patient's lifestyle patterns questionnaire results are unique—no two patients have identical results. Pattern scores range from 0 to 100% for the 21 patterns. The higher the score, the greater is the likelihood that a particular pattern is a dominant one requiring attention during counseling.
Because patients often have more than one highly scored pattern in each dimension, clinicians and patients will need to discuss and mutually agree on which patterns to tackle first. There is a spirit of mutuality in this patient-centered approach, in which patients are active participants.7 Together, the clinician and patient determine a strategic weight loss plan that the patient is willing to undertake. Choices may include the pattern a patient sees as most problematic, a pattern that is of particular interest to a patient, or one the patient feels will be easiest to address. For any patient who seems overwhelmed, one pattern may be enough to address during a single counseling session. However, for other patients who seem eager to learn and are capable, discussing two or three patterns may be appropriate. For all patients, it is recommended to address some eating patterns initially because dietary changes will have the greatest impact on weight loss.
The Lifestyle Patterns Approach offers clinicians a comprehensive weight management program with the goal of reshaping each patient's weight-gaining lifestyle patterns into weight-losing habits.3 The lifestyle patterns questionnaire results actually form the foundation for the personalized weight management treatment plan to follow.
Each of the 21 lifestyle patterns has its own two-sided patient teaching handout, available for printing and distribution to patients. Each handout has four targeted treatment strategies, all of which use evidence-based recommendations for weight loss and behavior change. Handout information is easy to read, with detailed tips for helping patients build their skills and confidence.
A clinician seeing the patient in Figure 2 would most likely want to address the two highest eating pattern types: Hearty Portioner and Fruitless Feaster. The four treatment strategies for the Hearty Portioner eating type are slowing down the pace of eating,re-proportioning one's plate by using the principles of energy density,learning about serving sizes, and avoiding portion traps, such as serving family-style at home with platters on the table. The four treatment strategies for the Fruitless Feaster are having produce ready and on hand, making fruits and vegetables flavorful, picking colorful produce, and eating more vegetarian meals. Clinicians and patients will enjoy the fact that there are often crossover benefits when counseling on different lifestyle patterns. For example, as a Fruitless Feaster, a patient learns to eat more fruits and vegetables, which will also help her Hearty Portioner tendencies as she learns to fill up on lower-calorie foods.
Although the Lifestyle Patterns Approach has symmetry in its development—seven patterns within the three lifestyle dimensions and four strategies for each of the 21 pattern types—this apparent“cookie-cutter” approach actually allows for much flexibility and personalization during counseling sessions. Clinicians can tailor their teaching to a patient's particular interests, abilities, and attentiveness by limiting or expanding the number of strategies or patterns discussed during each visit.
Lifestyle Patterns Approach forms help clinicians document, organize, and monitor patients' progress during follow-up appointments. A progress tracking chart will prompt clinicians to have patients grade their level of achievement in controlling the targeted pattern. For example, a patient may grade her ability to eat more fruits and vegetables (Fruitless Feaster) and to decrease her portion sizes (Hearty Portioner). Self-grading fosters discussion because a low grade (e.g., a C or a D) signals that the patient is still struggling with a particular pattern, whereas a higher grade (e.g., an A or a B)signifies that the patient is taking control and realizing some success. Once a patient is able to control a particular pattern, another pattern is chosen to discuss.
The lifestyle patterns questionnaire can be readministered after a 5–10% weight loss; this provides another objective measurement of progress, and patients typically see their pattern scores improve. This also encourages discussion regarding setting a new agenda for further counseling sessions. Readministering the questionnaire when a patient has reached a weight plateau or even gained weight can help clinicians better understand the patient's situation. A change in life circumstance (e.g., a job change,relocation, divorce, travel, illness, or injury) can lead to the development of a new pattern type not previously identified or an exacerbation of a previously identified pattern.
The Lifestyle Patterns Approach provides a framework for a targeted weight control program. This method can be used during one-on-one sessions or in group counseling. Whether they are physicians, nurse practitioners, nurses,registered dietitians, certified diabetes educators, fitness professionals, or psychologists, clinicians will have the information they need to counsel patients in all three dimensions of the program: eating, exercise, and coping. The team concept and the recognition that patients will sometimes need to be referred to another professional are also integral parts of this program.
Robert F. Kushner, MD, is the clinical director of the Northwestern Comprehensive Center on Obesity and a professor of medicine at the Northwestern University Feinberg School of Medicine in Chicago. Nancy Kushner,MSN, RN, is a nurse practitioner, the health content editor of diet.com, and a health writer in Chicago. For more information on the Lifestyle Patterns Approach or the recently published book on its use, visit www.counselingoverweightadults.com.
Note of disclosure: The Kushners are the authors of a recently published book on the Lifestyle Patterns Approach and have received consulting fees from diet.com, which offers an online self-help version of the approach.