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Weight Loss: Counseling and Long-term Management: A Physician's Toolbox of Counseling Strategies


A Physician's Toolbox of Counseling Strategies


Assessment is helpful in tailoring individual treatment approaches and targeting problem areas for change. Typical assessment areas include the degree of the patient's obesity, dietary patterns, physical activity patterns, emotional factors, and willingness to change.

Degree of Obesity. The degree of the patient's obesity will help determine the most appropriate intervention. Lifestyle change counseling strategies are most useful with patients who are overweight to moderately obese (BMI 25 to 40). More intensive approaches, including bariatric surgery, are indicated for heavier patients (BMI > 40).

Diet. Dietary evaluation ideally should be carried out by referral to a registered dietitian. If not practical, there are several brief tools, such as the MEDFICTS Dietary Assessment Questionnaire,[3] which can give some quick insight into the patient's dietary patterns. The advantage of a brief assessment tool is that the physician can see reliable information about the eating pattern in a minimum of time. The patient will also gain self-awareness about current eating behavior. The most efficacious diet for weight loss is a balanced, reduced calorie plan based on United States Department of Agriculture (USDA) guidelines.[4] A deficit of 500 to 1000 calories a day will result in a safe 1- to 2-pound weight loss a week. The USDA guidelines give a number of food choices that are graphically represented in the Food Guide Pyramid.[4]

Physical Activity. Physical activity can be quickly assessed by a number of questionnaires, including the Self-Administered 7-day Physical Activity Recall Questionnaire,[5] which can provide information to guide the physician in treatment planning.

Emotional Status. Assessment of emotional status is important. The Beck Depression Inventory for Primary Care (BDI-PC) is a self-administered brief questionnaire that helps identify depression in patients.[6]

Willingness to Change. Obese patients differ in their willingness to make changes. An understanding of the patient's level of willingness to adopt a sensible eating and physical activity plan can help in selecting the most appropriate treatment. The "Stages of Change" model classifies patients into one of several stages.[7] In the "precontemplation" stage, patients are not concerned about their weight. Personalizing their risk factors, including a discussion of how a modest weight loss will lower their blood pressure or lipids, may be helpful. In the "contemplation" stage, patients may be concerned about their weight but they may not yet be ready to do something about it. Some basic education about simple steps to improve a healthy lifestyle may be indicated. Patients in the "preparation" stage may have decided to do something but have not yet begun. Encouragement from the physician to make a commitment to health and well-being can frequently make a difference. Patients in the "action" stage are trying to do something, and are most likely to benefit from lifestyle change counseling strategies. Patients in the "maintenance" stage are managing their weight and are usually helped by a physician's moral support and recognition.

Lifestyle Change Counseling Strategies

To help an obese patient develop a healthy lifestyle, there are a number of cognitive behavioral counseling strategies that have been shown to be especially efficacious and can be part of a physician's counseling toolbox.

Realistic Goals. When asked, patients often have unrealistic weight-loss goals. Using dietary and exercise counseling strategies, the average patient will lose about 8% to 10% of body weight, a weight loss that will improve risk factors but will be disappointing to many individuals.[4] We typically help the patient set moderate short-term goals, such as making small increases in daily walking and decreases in portion sizes. We also help the patient focus on the psychological improvements, such as improvements in well-being and feeling better about oneself, and the health benefits of this modest weight loss. Goals are reevaluated periodically and revised when necessary. Patients feel good about meeting modest goals and typically approach longer goals, including maintenance, in a better frame of mind. We sometimes remind patients that unrealistic short-term goals, such as losing weight too quickly, typically result in failure and frustration.

Self-monitoring. If physicians had only the time to counsel patients in one behavioral strategy, self-monitoring is the one we would advise.[8] For patients to change dietary and physical activity, it is critical that they know what they are eating and how much they are exercising. Raising self-awareness is absolutely necessary. We require that patients keep food records. They are asked to write down what they eat during the day and look up the calories. We also ask them to keep track of the minutes they exercise or the number of steps they take each day if they are using a pedometer. We don't particularly care how accurate they are in their recording. We know that patients underestimate their energy intake by an average of one third and overestimate their physical activity by about one half. The reason that food and physical activity records work is that they help raise self-awareness. It is interesting that many physicians do not ask their patients to keep records and that many patients do not like to keep them. Yet food and physical activity records are the most important of all behavioral counseling strategies.[8] To increase awareness of body weight, weighing on a regular schedule, usually daily during a weight-loss program and weekly during weight maintenance, should also be strongly encouraged.

Meal Replacements. Meal replacements have become a significant tool for helping manage body weight over the long term.[9] There are many published peer-reviewed studies documenting the role that meal replacements play in long-term weight loss and maintenance.[10] Substituting 2 meals with a meal replacement for weight loss and substituting 1 meal for weight maintenance has shown excellent efficacy with no significant safety concerns. We are currently using a meal replacement in Look AHEAD (Action for Health in Diabetes), a major multicenter clinical weight-loss trial sponsored by the National Institutes of Health that is evaluating weight loss and weight maintenance for the prevention of cardiovascular morbidity and mortality in obese patients with type 2 diabetes.

Stimulus Control. Stimulus control involves identifying and modifying the problems contributing to dietary and exercise lapses.[11] Using food and physical activity records, a brief discussion of problems encountered since the last visit can lead to strategies to overcome particular barriers the patient faced. Traveling, eating in restaurants, and late-night eating are often culprits. Having the patient come up with solutions to overcome the problems is especially helpful. Carrying meal replacements while traveling, calling restaurants ahead of time and asking about sensible items that can be ordered without breaking one's dietary pattern, or planning realistic evening snacks may be useful strategies for dietary management.

Managing Stress. Stress is a major predictor of relapse from healthy lifestyle patterns.[11] A discussion of stressful life events may help patients identify problems that need to be handled to make it easier to manage their lifestyles. Teaching a patient how to manage stress can be particularly helpful. Increasing physical activity is an excellent tool for managing stressful situations because it significantly improves well-being. Meditation can help. Progressive muscle relaxation, a technique that involves muscle tensing and relaxing, can be learned quickly and lead to rapid stress reduction.

Cognitive Restructuring. Cognitive restructuring involves helping patients change the way they think about themselves.[12] We find that some patients believe that losing weight will somehow magically bring them happiness in all aspects of their lives. Some patients who have been heavy all their lives have difficulty accepting their new leaner bodies. Our purpose in cognitive restructuring is to help patients develop self-enhancing, self-affirming thoughts. We have patients come up with their own positive self-affirmations, such as "I will shut off the television at 6:00 PM and go outside and walk briskly for 45 minutes." Self-affirmations can be powerful reminders to help patients stay on course.

Relapse Prevention. Relapses are a normal part of the weight-loss process. Counseling patients about how to deal with relapses includes helping them understand that lapses are to be expected and to prepare them to deal with lapses by getting right back on track. When patients learn to anticipate lapses and practice individual coping strategies, a total collapse may be avoided.[12]

Social Support. Support from others has been shown to be valuable in both weight loss and weight maintenance.[11,12] Ideally, a family that eats the same healthy foods together and exercises together is the perfect support group. Other support groups may include friends or groups of similarly minded individuals. Support groups work by providing role models, allowing self-acceptance, and serving as an outlet for the emotional issues that patients sometimes experience during a weight-loss intervention.

Contracts. Contracting with patients involves asking them to verbalize at least 1 behavior change that they agree to make over the next month.[12] Examples may be to increase walking from 15 minutes to 30 minutes a day, to increase the number of days walked from 3 to 5, or to limit desserts from a current 4 days a week to 2 days a week. The behavior should be specific and realistic. The patient is then asked to write the behavior change down and sign the contract. Contracts can be quite motivating for short-term change.

Pharmacotherapy. Although lifestyle change counseling strategies are helpful for many patients, pharmacotherapy can be a useful addition to the physician's toolbox of strategies for helping some patients adhere to a healthy diet. There are 2 obesity drugs that the Food and Drug Administration (FDA) has approved for long-term use: sibutramine[13] and orlistat.[14]

Sibutramine is a selective serotonin and noradrenaline reuptake inhibitor. Its primary mechanism of action is increased satiety. Sibutramine has shown good efficacy in long-term trials with clinically approved doses of 10 to 15 mg.[13] It does have a consistent effect of increasing blood pressure and pulse, so blood pressure and heart rate should be carefully monitored. Sibutramine may not be applicable for patients with significant cardiovascular disease.

Orlistat is a lipase inhibitor that works by reducing the body's absorption of about 30% of dietary fat. Orlistat also has shown good efficacy in long-term trials.[14] Patients are asked to take 120 mg, 3 times a day -- 1 dose at each of the main meals. Orlistat treatment effects include changes in bowel habits, including oily or loose stools, the need to have a bowel movement quickly, oily spotting, or bloating. These effects tend to occur when patients eat a diet containing more than 30% of calories from fat. We find that orlistat also works as a behavior-modification strategy by encouraging patients to maintain a lower-fat diet to avoid the gastrointestinal treatment effects. Because the drug blocks dietary fat, it reduces absorption of fat-soluble vitamins, so patients require a multivitamin supplement.

Brief Counseling

Because most physicians and other healthcare professionals do not have as much time as they would like to counsel patients, we recently completed a study assessing the efficacy of monthly 15- to 20-minute counseling sessions in which we attempted to develop the basic elements of the counseling process (Poston WSC, Haddock CK, Pinkston MM, et al. Can obesity be treated only with pharmacotherapy? 2004; manuscript currently under editorial review.) The table below illustrates the components of our brief weight-loss/weight-maintenance counseling sessions. The key elements include a brief review of the food and activity records if the patient has kept them, a review of the goals from the last visit, a review of problems and solutions, the setting of new goals, a new behavioral contract for the patient to sign, and positive feedback and encouragement. We congratulate all successes and do not criticize -- ever.

Table. Brief Counseling Session

Review food/physical activity records
Review goals from last visit
Review problems and solutions
Set realistic goals
Sign behavioral contract
Give positive feedback and encouragement

Table of Contents

  1. Introduction
  2. A Physician's Toolbox of Counseling Strategies
  3. Summary
  • Print