Document 178480

CLinical review
How to Deliver High-Quality Obesity Counseling
in Primary Care Using the 5As Framework
Sheira Schlair, MD, MS, Sarah Moore, MD, Michelle McMacken, MD, and Melanie Jay, MD, MS
Abstract
• Objective: To review the content of the 5As of obesity
counseling for primary care physicians as well as
strategies to efficiently address the 5As during a typical 20-minute visit.
• Methods: Review of the literature.
• Results: Obese patients are evaluated in the primary
care setting for multiple weight-related comorbidities
and often seek help from their primary care providers
to lose weight. Several studies have suggested that
physicians and other providers do not adequately
counsel obese patients about their weight because
of barriers such as poor reimbursement, lack of
obesity-related counseling skills, and lack of time.
The 5As (Assess, Advise, Agree, Assist, Arrange)
is an evidence-based, behavior-change counseling
framework endorsed by the Centers for Medicare and
Medicaid Services and the United States Preventive
Services Task Force.
• Conclusion: With the recent announcement that Medicare will now cover intensive behavioral counseling
for obese patients, more providers may be interested
in gaining the necessary skills to provide high-quality
weight management counseling.
A
pproximately one-third of the US population
is obese, and that number has grown over the
last 20 years [1]. Several large trials of lifestyle
interventions have shown that sustained weight loss is
achievable and that even modest weight loss (ie, 5%
to 10% loss of body weight [2]) is clinically beneficial.
Primary care physicians are ideally situated to promote
weight loss via effective obesity counseling. They have
longitudinal relationships that enable rapport building
and behavioral change management with a large percentage of the population, and are experts in managing
chronic diseases and health conditions. The United
States Preventive Services Task Force (USPSTF) recomwww.jcomjournal.com
mends that primary care providers screen patients for
obesity and offer intensive behavioral treatment [3].
However, the literature reveals that primary care physicians may lack confidence and competence in managing
obesity [4], largely due to lack of systematic counseling
skills [5], negative attitudes [6], and lack of time [7,8].
In addition, lack of reimbursement has been an
obstacle to providers in counseling obese patients [9].
Luckily, compensation for such interventions is changing: the Centers for Medicare and Medicaid Services
(CMS) recently announced that Medicare will now cover
intensive behavioral counseling for obese patients [10].
Specifically, primary care physicians will be reimbursed
for weekly visits for the first month and then every other
week for months 2 through 6. Given the efficacy of
weight loss interventions and the potential remuneration
for frequent visits, primary care physicians should be
comfortable providing basic weight management counseling for their patients.
The purpose of this paper is to guide providers on
incorporating obesity treatment into their practice using
the 5As model for obesity counseling. This model guides
the provider to assess risk and readiness to change, advise
specific behavior changes, agree on specific goals in a
collaborative manner, assist via addressing barriers (motivational interviewing), and arrange to follow-up or refer
the patient for further treatment. Both the USPSTF and
CMS have advocated using the 5As model for obesity
counseling [10]. The 5As model, initially found to be effective when used by primary care physicians to promote
smoking cessation [11], has since been adapted for use in
obesity counseling training for primary care physicians
and has been found to promote physician obesity counseling competence [5,12–14]. The model is also useful as
From the Montefiore Medical Center/Albert Einstein College
of Medicine (Dr. Schlair) and the New York University School
of Medicine (Drs. Moore, McMacken, and Jay).
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Obesity Counseling
a clinical reminder in an electronic medical record [15]
and may impact patient outcomes in physician training in
graduate and continuing medical education [13,16,17].
There are few studies that have examined the efficacy
of using the 5As for weight management in patients. In a
pilot study examining the use of 18 counseling practices
related to the 5As, obese patients (n = 137) reported on
the use of the 5As by primary care residents (n = 23). Each
additional 5As counseling practice was associated with
higher odds of being motivated to lose weight (odds ratio
[OR] = 1.31, 95% confidence interval [CI] 1.11–1.55) and
intending to eat better (OR = 1.23, CI 1.06–1.44) [13,18].
A larger study where researchers audiotaped primary care
encounters between 40 physicians and 461 obese patients
and followed patients for 3 months showed higher confidence to lose weight in patients where the physician “assessed” and “advised” them to lose weight, lower fat intake
when the physician “assisted” and “arranged,” and higher
weight loss when the physician “arranged.” This study
examined a slightly different 5As framework, and thus did
not evaluate the impact of “agree.” We know of at least one
ongoing study that will examine the impact of using the
5As of weight loss outcomes, but the results have yet to be
published.
We believe that the 5As is a useful model that highlights
the skills needed to provide high-quality, behaviorally
based obesity counseling. Here we will outline the content of each of the 5As as adapted for obesity counseling
skill development. Furthermore, we will discuss how to
complete the 5As in a time-efficient manner while recognizing that in a busy primary care practice addressing all
the “As” can be done over several visits.
ASSESS
For a patient seeking treatment for obesity, there are many
areas to assess. As outlined in the “assess” section of
Table 1, the health care professional’s initial task is to
evaluate obesity risk, motivation to lose weight, history of
weight loss efforts, current dietary and exercise behavior,
and current expectations of medically supervised weight
loss. For a continuity visit, the past medical history and active comorbidities are usually known; the body mass index
(BMI) can be calculated at triage.
Risk Assessment
The first step is determining who should be counseled.
This starts with calculating the patient’s BMI using his
or her current height and weight. Overweight status is
222 JCOM May 2012 Vol. 19, No. 5
defined as a BMI in the 25–29.9 range and obese status
is 30 or greater [19]. In general, weight loss should be
recommended to all patients with a BMI greater than
30 and those with a BMI 25–29.9 who have 2 or more
risk factors for cardiovascular disease. For overweight
patients without risk factors or those who cannot undergo weight loss, efforts should be focused on weight
maintenance or prevention of further weight gain [20].
Obesity risk includes the patient’s obesity-related risk
(including BMI and/or waist circumference), cardiovascular risk factors (hypertension, diabetes or prediabetes, dyslipidemia, family history of early myocardial infarction, tobacco use), and obesity-related disease
(eg, diabetes, osteoarthritis, obstructive sleep apnea,
fatty liver disease, stress incontinence, polycystic ovarian syndrome.) Using this information, the physician
can later explain the risks and benefits of weight loss
tailored to the individual patient. It is often helpful to
initially ask for permission to discuss a patient’s weight.
This technique will make any resistance readily apparent
on a potentially sensitive topic: “Is it OK if we spend a
little bit of time discussing your weight, exercise, and
dietary habits?”
Weight Loss History
Before assessing current diet and exercise behavior, the
provider should ask the patient about history of weight
loss attempts, successes, and circumstances. This conversation may elicit many of the patient’s ongoing barriers to weight loss. Anecdotally, many patients who have
attempted to lose weight using fad diets or extreme calorie restriction may initially be successful but then often
regain the weight several months later. This observation
can be pointed out to the patient later on as a way of
supporting the idea of sustainable, gradual weight loss.
Readiness for Weight Loss and Expectations
Finally, readiness to lose weight is guided by assessing
interest and confidence in weight loss on a scale of 0
(no interest/no confidence) to 10 (very interested/very
confident) and considering the patient’s stage of change,
which may be defined as pre-contemplative, contemplative, preparation, action, maintenance or relapse [21]. It
should be recognized that certain major life events (recent move, new job, divorce, recent loss) might preclude
commitment and attention to weight loss.
Finally the provider lays the groundwork for setting
realistic expectations by asking “How much weight do
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CLinical review
Table 1. The 5As of Obesity Counseling
Assess
BMI
Comorbidities (metabolic syndrome, diabetes, high cholesterol)
Family history (including family history of obesity)
Psychiatric history
Current depressive/anxiety symptoms and coping mechanisms
Medications
Previous weight loss attempts
Dietary behavior
Exercise
Stage of change
Social history and interpersonal barriers to weight loss
Advise
Weight loss: specifics! 5%–10% over 6 months
Review patient’s weight loss goals
Suggest changes to diet
Suggest changes in physical activity
Discuss treatment options for psychosocial co-morbidities
Give information about treatment options: (1) Medication pros and cons when appropriate; (2) Surgery pros/cons when appropriate
Address patient’s concerns and answer questions re treatment options
Agree
Clarify patient’s preferences about behavior change options that you advised/discussed with the patient
Allow patient to help choose 1–3 mutual behavior change goals
Give written exercise /diet prescription based on the goals
Make sure the goals are SMART (specific, measurable, achievable, realistic, and time-bound)
Make it clear when you will check in again with the patient to monitor adherence to these goals
Make sure that these goals are revisited and revised during subsequent visits
Assist
Address barriers to change
Help patient reflect on support systems
Verbalize your support for patient’s goals, be empathetic
Describe services that can offer patient support (group therapy, nutritionist, CBT therapist, etc)
Prescribe medications and/or refer to bariatric surgery
Apply motivational interviewing skills to stages of change/transtheoretical model to help move patient further in their stage of change and activate the patient to change behaviors
Arrange
Frequent follow-up
Referral to weight-management clinic
Referral to community resources/commercial programs
Bring family members/social support in weight loss plan to future visits if applicable
you want to lose?” and “How long do you expect that it
will take you to lose this weight?”
Current Behaviors
In the next part of the assessment, the health care professional elicits information from the patient regarding
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current dietary and exercise habits. There are several
possible approaches. One option may be to ask the patient to recall everything he or she ate in the last 24
hours, including drinks and condiments. While this
might not reflect what the patient typically eats, it does
provide a detailed starting point for further discussion.
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Another approach might be to have the patient describe
a typical day, with attention to typical foods chosen for
each meal as well as daily activities and routines. Finally,
patients can be asked to keep a more prolonged daily
dietary and exercise log [20] that can be reviewed at
the next visit. With any of these approaches, attention
should be paid to eating patterns (regular meals including breakfast), methods of food preparation (homecooked vs. take-out), and emotional or social triggers
to overeat.
For example the health care professional might ask:
“How many times a week do you skip breakfast?”
“Please tell me everything that you ate and drank yesterday. This will help me to get a sense of your habits.”
“Do you regularly drink sodas, bottled teas, sports drinks,
or juice?”
“What vegetables and fruits do you eat on a regular
basis?”
“What type of exercise or activities do you enjoy?”
ADVISE
Method and Amount of Weight Loss
The primary care physician advises specific behavior
changes and timing based on the patient’s individual
obesity risk factors, as described in the “advise” section
of Table 1. A healthy weight loss goal is defined as on
average no more than 1 to 2 pounds of weight loss per
week or 5% to 10% weight loss in the first 6 months [2].
The primary care physician should then probe the
patient for his or her goals and break down long-term
weight loss goals into behaviorally specific short-term
goals. This is the time to correct any misconceptions
about what successful and clinically significant weight
loss means for the individual patient: “For you, losing
just 15 pounds over the next 6 months will reduce your
risk of getting diabetes by 60% over the next few years!”
Dietary Counseling
Generally, dietary advice should be focused on making lower-calorie choices in the form of small changes
that are sustainable. Low-fat, low-carbohydrate, and
Mediterranean-type diets have been heavily promoted, but their effectiveness has yielded mixed results
[22–24]. Therefore, a specific diet should be guided by
224 JCOM May 2012 Vol. 19, No. 5
patient individual preferences and comorbidities with an
emphasis on lifestyle changes. Rather than focusing on
diets, which many patients cannot sustain, the approach
should be to promote goal setting around changes that
patients can maintain for the rest of their lives. It may
be helpful to start by asking patients how they think
they could improve their diet and allow the response to
guide the discussion.
We recommend 2 strategies for providing dietary
advice: the SERVE method and the plate method. The
first is based on the mnemonic “SERVE” that provides
rapid assessment of habits that may be high-yield for
change. “SERVE” reminds the health care professional
to ask about:
Sugar-sweetened beverages and other liquid calories
[25–27]
Exercise habits [28–31]
Regularity of meals (especially breakfast) [32,33]
and Restaurant use
Vegetable- and fruit-rich-diet [34–37]
Eating less or portion-size awareness [38–40]
SERVE is a useful mnemonic developed at our institution to train resident physicians, but its effectiveness for
obesity counseling has not been studied.
The plate method is an uncomplicated way to control
portion sizes that was originally developed for nutritional
counseling in diabetic patients. In this model (www.
platemethod.com), vegetables take up at least half of the
plate. The other half is subdivided, with starchy foods
(bread, rolls, cereals, potatoes, beans) taking up ¼ of the
plate and protein (meat, fish, soy, cheese) the other ¼
of the plate. The recommended plate size is 9 inches in
diameter. Drawing the plate or providing a picture offers
a meaningful visual reference for the patient on portion
size. An initial goal may be to make 1 meal a day look
like the plate.
The data regarding the efficacy of the plate method for
weight loss counseling in a primary care setting is limited.
A small pilot study that included 65 primary care patients
randomized to a portion control plate versus standard patient education handouts showed improve weight loss at 3
months in those patients using the plate [41].
Meal replacement options have been found to be an
effective management strategy as well, as noted in a 2003
meta-analysis [42]. There are several commercially availwww.jcomjournal.com
CLinical review
able products (typically shakes or snack bars) that can
be used as meal replacements though there are no highquality comparative effective analyses to determine which
types are best. Consideration such as price, taste, and clinician and patient preference may guide selection. Meal
replacements can be used to substitute for one or more
meals but we do not recommend that clinicians advise
patients to use meal replacements exclusively (ie, a liquid
diet) without further training in how to monitor such
patients safely.
Physical Activity Counseling
It should be noted that intensive physical activity alone
does not reliably lead to (or promote) weight loss. However, exercise has been shown to be an effective weight
maintenance measure and helps improve overall health.
Questionnaires are available to facilitate the assessment
process [43]. Physical activity should be increased slowly
from the patient’s baseline level in order to avoid injuries.
A long-term goal of at least 30 minutes of moderate intensity activity on most, preferably all, days of the week is
appropriate for all adults.
AGREE
This portion of the model is where goal setting occurs.
Goal setting is associated with effective lifestyle behavior change [44,45]. The health care professional and
patient agree and set specific behavioral goals for weight
loss. Current goal setting theory, much of which is derived from the occupational psychology literature, states
that to maximize goal attainment, behavior change
goals should be specific, proximal, and set collaboratively with the provider [45–47]. These goals are ideally formed during negotiation using patient-centered
interviewing skills in which the physician and patient
mutually agree upon 1 to 3 behaviorally specific weight
loss goals, based upon the patient’s personal goals and
the content of the health care professional’s advice offered while “advising”:
“Given all that we’ve just discussed—my advice and your
reflections—what specific changes in your diet would you
like to make?”
“What changes are you willing to commit to starting
today?”
“May I offer you some suggestions based on what you
already told me?”
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As stated above, it is important that goals are as
specific and realistic as possible. For example, “I would
like to walk more” is far less likely to be achieved than
“I would like to walk 20 minutes, 5 days per week with
my dog after work and I will record my progress in an
exercise diary until our next visit.” It is most realistic to
choose only 1 to 2 specific goals, and these may be small
behavior changes rather than sweeping lifestyle changes.
Patients who achieve small goals may have more confidence to set higher goals [24,48].
It is also important to establish that goals should be
set as a commitment to long-term lifestyle changes that
they will maintain. We suggest that it is important that
that providers document goals both in the electronic
medical record and on a prescription for the patient to
take home, with the expectation that they will be asked
about these goals at the following visit.
There are many tools available to help guide this
process including the plate method as mentioned above,
portion control and monitoring, and dietary and exercise monitoring tools [43]. Many of these tools can
be used iteratively for assessing, advising, assisting and
agreeing.
ASSIST
While this may be one of the most useful of the 5As, it is
one of the least practiced parts of the 5As model [49,50].
As noted in Table 1, the primary care physician assists in
addressing barriers with the patient and securing support.
Assist may also involve prescribing weight loss medications, using meal replacements, or referring for bariatric
surgery evaluation. While nonbehavioral obesity treatments are beyond the scope of this review, they should be
offered in conjunction with high-quality counseling.
Behavioral Therapy
For some patients, important barriers must be addressed
prior to committing to intensive weight loss efforts. For
example, depression and other psychiatric disorders should
be adequately treated. A focus on stress management
techniques and stimulus control may improve compliance
with dietary and physical activity changes. Patients should
develop a habit of self-monitoring, which has been shown
to be one of the most commonly reported strategies for
long-term weight maintenance [43]. This includes keeping
food diaries, logging exercise time, and frequently monitoring weight. Food diaries should include information
about portion/volume of intake, time consumed, and type
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of food and drink. Activity logs should include information about activity performed, time spent doing activity,
and intensity.
Motivational Interviewing
While many patients would like to lose weight, they may be
ambivalent about change or lack confidence. Motivational
interviewing can address these barriers and has been shown
to enhance the effectiveness of weight loss interventions
[51,52]. It is a patient-centered, directive method for enhancing intrinsic motivation to change by exploring and
resolving ambivalence [53]. Evocation, one of the core
principles of motivational interviewing, involves eliciting the
patient’s rationale for change rather than stating the physician’s rationale. The underlying philosophy is that human
beings are generally ambivalent about behavior change.
Empathy, avoiding argument, and supporting self-efficacy
are emphasized. In brief, there are several key skills that may
help in exploring and managing the patient’s ambivalence to
change. Some examples of skills include open-ended questions, reflective listening, affirmations and summarizing to
further support self-efficacy, as illustrated below:
“How has your life been affected by your weight?”
or
“How do you anticipate things would change if you met
your weight loss goal?” (Open-ended questions)
“Sounds like you were really frustrated when your last
diet failed.” (Reflective listening)
“So, you want to prepare more vegetables, but you anticipate that your family may protest” (Reflective listening)
“I appreciate your willingness to discuss those painful
experiences.” (Affirmations)
The primary care physician can probe the patient’s underlying ambivalence about weight loss or maintenance
by then weighing the interest and confidence against one
another, as was noted in the Assess section above. For
example, “I hear you that your interest in losing weight
is a 10 and your confidence is a 6. Why did you give your
confidence rating a 6 instead of a 1? On the other hand,
why didn’t you give it a 10? What would help you be
more confident?”
When a primary care physician assesses motivation
and confidence, they can go one step further and actually develop discrepancy. In other words, change can be
motivated when there is a discrepancy between a patient’s
226 JCOM May 2012 Vol. 19, No. 5
current behavior and his or her goals and values (eg, “I
noticed that you say you want to lose 20 pounds but at
the same time have been eating fast food because it is easier with your busy schedule”). The physician emphasizes
small steps as successes such as taking the stairs or coming to appointments even if the patient has failed to lose
weight. For many patients struggling with weight loss,
their ambivalence may relate to the burden of constant
vigilance rather than whether weight loss is necessary.
This is especially true when patients hit a weight plateau
despite ongoing efforts. The plateau is an expected part
of medical weight loss that patients should be anticipating. Once patients reach their weight loss goals, the focus
shifts to weight maintenance using the 5As.
ARRANGE
The health care professional and patient must arrange
for close follow-up to promote effective weight loss as
well as referrals. Patients lose significantly more weight
when they are part of an intensive lifestyle intervention
as compared with standard of care; per recent CMS recommendations, primary care physicians who cannot perform intensive counseling should refer to more intensive
programs. Reimbursement will occur for 1 face-to-face
visit every week for the first month; 1 face-to-face visit
every other week for months 2 to 6; 1 face-to-face visit
every month for months 7 to 12, if the patient meets
a 3-kg weight loss requirement [10]. For patients who
do not achieve a weight loss of at least 3 kg during the
first 6 months of intensive therapy, it is appropriate to
reassess BMI and readiness to change after an additional
6-month period. Successful models include a combination of weekly group visits, monthly individual sessions,
and frequent use of self-monitoring tools like food diaries
[54,55]. Individual follow-up appointments consist of
a reiteration of 5As, specifically focusing on barriers to
meeting goals and setting new goals. Telephone followup may be an effective option as well [56].
A TIME-EFFICIENT APPROACH TO THE 5As
Within the construct of CMS-reimbursed weekly and
biweekly visit schedule, the first visit should focus on assessment, agreeing on a weight loss goal, and having the patient
keep a food and activity diary. Much of the assessment can
be done during a first visit as part of general history and
physical exam. The second visit could incorporate reviewing
the food diary, agreeing on goals using the SERVE or plate
method, and assisting in addressing barriers. Subsequent
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CLinical review
Table 2. Time-Efficient 5As (in 1 visit)
ASSESS – 5 minutes: Ask patient about weight management,
diet, exercise, history of weight loss, stage of change and
interest/confidence
ADVISE – 3 minutes: Provide clear, strong advice to lose
weight with personalized messages about the impact of obesity on health
AGREE/ASSIST – 5 minutes: Negotiate 1–3 mutual goals and
address barriers, suggest treatments, provide and discuss
social support in weight loss plan
ARRANGE – 2 minutes: Make referrals, arrange frequent
follow-up
visits should involve monitoring goals and assisting and arranging for more intensive services, if necessary.
One may advise and assist or even arrange depending on
where the patient is on the stage-of-change continuum. If a
patient is in the action stage and is knowledgeable, the primary care physician may spend more relative time arranging
than with a patient with poor knowledge about nutrition
and/or exercise that is pre-contemplative or contemplative.
All in all, obesity counseling using the 5As is an iterative
process in which the physician uses the 5As repeatedly over
time with the patient (Table 2 and Table 3).
CONCLUSION
In general, behavioral counseling for obese patients
can produce modest, though still clinically significant,
long-term weight loss. Despite the paucity of studies
examining the efficacy of the 5As in promoting weight
loss, we believe that the 5As is a practical model for approaching obesity counseling. In this paper we reviewed
the evidence for and concrete day-to-day use of the
basic components of the model. Most importantly, obesity counseling is not synonymous with advice giving.
This model guides the physician to use a collaborative,
patient-centered approach to behavior change while respecting patient autonomy.
Corresponding author: Sheira Schlair, MD, MS, CFCC,
1621 Eastchester Rd., Bronx, NY 10461, [email protected]
Financial disclosures: None.
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Table 3. Longitudinal Approach to 5As of Obesity
Counseling
Much of the assessment can be done during first visit as part of
general history and physical exam
You may dedicate 5–10 minutes of revisit session to discussing
diet and exercise goals and have frequent visits
You may give the patient a food diary and exercise log and then
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In that 15-minute revisit, review diary using SERVE and plate
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